Rehabilitation SNF Level of Care

1. Rehabilitation (Rehab) skilled nursing facility (SNF) services are covered when the following guidelines are met.
   1. Rehab services must be provided with the expectation that:
      1. There will be improvement in the patient's functional mobility, participation in self-care activities and/or cognitive-communicative skills within a reasonable and predictable period of time, and
      2. The improvement will be of significant and practical value to the patient when measured against the patient's condition at the start of the rehabilitation services.
   2. Rehab services must be of a level of complexity that requires the skills of a qualified physical, occupational and/or speech therapist.
   3. Rehab services also must meet all of the following.
      1. Services must be performed according to accepted standards of medical practice.
      2. The treatment must be specific and effective for the patient's condition.
      3. The amount, frequency and duration of treatment must be reasonable and necessary.
      4. An active treatment plan must be in place that is directly and specifically based on an evaluation performed by a qualified therapist and approved by the patient's physician.
      5. Rehab services cannot be effectively and safely provided in a less intensive setting, such as in an outpatient or home setting.
   4. Rehab services are provided for a minimum of 150 minutes per week and at least 5 days per week for up to 30 days.
   5. Additional Rehab SNF services are covered for up to a maximum of 14 days, when the all of the following guidelines are met:
      1. Medical record documentation supports that the patient has had a decrease in function due to a medical condition during the 30 day period.
      2. The criteria outlined in Section I.A1. through 4, continue to be met.
      3. Precertification is not required. However, HMSA reserves the right to perform retrospective review for medical necessity.
2. Limitations
   1. Services beyond 44 days will not be covered.

Reference

1. Medical Benefit Policy Manual, Publication 100-02, Chapter 8 Coverage of Extended Care (SNF) Services Under Hospital Insurance, Section 30.4.1.1 Direct Skilled Rehabilitation Services to Patients, General. 

Revision History