Point32 Skilled Nursing Facility and Rehabilitation Facility Authorization (PM) Form
This procedure is not covered
Harvard Pilgrim Health Care a Point32Health company
Referral, Notification, and Authorization-Authorization
Skilled Nursing Facility and Rehabilitation Facility Authorization
Unless otherwise specified, information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport ConnectSM. For UnitedHealthcare’s related policies/procedures, please go to www.UnitedHealthcareOnline.com or call 800-708-4414.
Inpatient Skilled Nursing Facility and Rehabilitation Facility Criteria
Prior authorization is required for inpatient admissions to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term acute hospitals (LTACs).
Covered services must be reasonable and medically necessary for treatment of the member’s illness/injury and provided by a contracted provider. Inpatient admissions are authorized only when, as a practical matter, requested services must be provided in an inpatient setting, and/or cannot be safely provided in a less restrictive, more cost-effective setting.
Harvard Pilgrim’s SNF and Sub-Acute Level of Care Guidelines, and Inpatient Rehabilitation/Long Term Acute Care Medical Review Criteria are available online in the Medical Management section of Harvard Pilgrim’s provider site at www.harvardpilgrim.org. A copy of current Medical Review Criteria may also be obtained by contacting Harvard Pilgrim’s Provider Service Center at 800-708-4414.
Action Required
Authorization should be requested prior to the date of admission (at least one week in advance when possible) to allow Harvard Pilgrim sufficient time to evaluate member eligibility.
The facility, PCP or specialist may request authorization by submitting an Extended Care Facility (ECF) Fax Request Form to 617-509-1147.
Harvard Pilgrim Response: The request is reviewed by a nurse reviewer, and the requestor will be contacted if additional clinical information is needed. Review is completed within two business days after receipt of the required medical information. The decision will be communicated by telephone within one business day.
If an inpatient admission occurs outside of normal business hours, the receiving facility may initiate services, but must contact the Harvard Pilgrim Triage Huntline no later than the next business day, to request authorization.
Information Required
- Member’s name and Harvard Pilgrim identification number
- Admitting physician’s name and National Provider Identifier (NPI)
- Facility name, location and National Provider Identifier (NPI)
- Service(s) requested
- Diagnosis and clinical information
- Admission date
- Medical information
HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL
August 2017
Harvard Pilgrim Health Care a Point32Health company
Referral, Notification, and Authorization-Authorization
Authorization Changes
Harvard Pilgrim must be informed when any change to an authorized admission occurs, such as a change in the authorized date of admission or cancellation of the admission. The provider must call the CSA Huntline at 617-509-1035.
PUBLICATION HISTORY
- 01/01/12 removed First Seniority Freedom information from header
- 03/15/16 updated authorization request information; updated authorization changes information
- 05/03/15 updated inpatient admissions outside of normal business hours information
- 08/15/17 added ECF fax request form information; updated the "authorization changes" section
HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL
August 2017