Independence closely reviews skilled nursing, subacute, and inpatient
rehabilitation admissions for medical necessity and to ensure our members are
receiving the right level of care and in the most appropriate setting.
As outlined in the Provider Manual for Participating Professional
Providers and/or Hospital Manual for Participating Hospitals,
Ancillary Facilities, and Ancillary Providers, we would like to remind you
that Independence follows therapy guidelines set by the Centers for Medicare
& Medicaid Services (CMS), and InterQual®, a product of
Change Healthcare, an independent company.
According to CMS and InterQual therapy guidelines, the minimum required
hours for the following services are:
- Skilled Nursing Facility. At least 1 – 2 hours of
direct physical, occupational, or speech therapy per day, at least 5
days/week.
- Subacute facility. At least 2 hours of direct therapy
(physical, occupational, or speech therapy) per day, at least 6 days/week
(i.e., at least 12 hours of direct therapy per week). Member must be physically
and cognitively willing and able to participate in, and benefit from, the
rehabilitation program.
- Inpatient rehabilitation. At least 3 hours per day direct
physical, occupational, or speech therapy per day, at least 5 days/week.
Physician intervention at least 3 times/week.
To protect against delays in advancing medical care and service, we will be
evaluating the following with each concurrent review:
- follow-up appointments are timely;
- members are receiving appropriate skilled therapy hours and number of
days;
- members are discharged timely and discharge plans are continually reviewed
and updated to reflect the members functional status and expectations;
- Notice of Medicare Non-Coverage (NOMNC) is delivered timely.
If you have any questions regarding these guidelines, please contact Sheila
Van Daly, Manager, Clinical Services, at Sheila.VanDaly@ibx.com.