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Acute Inpatient Rehabilitation Criteria

Approved:  5/07
Reviewed:  1/09, 1/13, 3/14,1/15, 1/16, 1/17
Revised:  2/08, 3/10, 2/11, 1/12, 1/15
 

Inpatient Rehabilitation Facility services provide multidisciplinary approach in a hospital setting to restore or enhance function after and illness or injury.  The services are appropriate for patients with complex nursing, medical management and rehabilitative needs. Determinations of whether inpatient rehabilitation facility services are reasonable and necessary must be based on an assessment of each patient’s individual care needs. The following criteria must be met at the time of admission for inpatient rehabilitation care to be considered reasonable and necessary.

 

Custodial care is care that can be given by non-professional staff and is not considered skilled care.  Custodial care is not covered under your medical plan.

 

  1. Require active and ongoing intervention of multiple therapy disciplines (Physical Therapy-PT, Occupational Therapy-OT, Speech-language Pathology-SLP, or prosthetics/orthotics), at least one of which must be physical therapy or occupational therapy.
  2. The patient must require an intensive rehabilitation therapy      program.
    • The program generally consist of at least 3 hours of therapy per day at least 5 days per week or;
    • In certain well-documented cases, at least 15 hour of intensive rehabilitation therapy within a 7-consecutive day period, beginning with the date of admission to the inpatient rehabilitation facility.
  3. The patient must reasonably be expected to actively participate in, and benefit from, the intensive rehabilitation therapy program at the time of admission to the inpatient rehab facility.  The patient can only be expected to benefit significantly from the intensive rehabilitation therapy program if the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient’s functional capacity or adaptation to impairments) as a result of the rehabilitation treatment, and if such improvement can be expected to be made within a prescribed period of time.     
  4. The patient must require physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation.  The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay in the inpatient rehab facility to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process. 
  5. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation.
  6. The patient should have an identified discharge disposition.

Skilled staff in the Inpatient Acute Rehabilitation program include:

    • Rehabilitation Physician
    • Rehab Certified Registered Nurses
    • Physical Therapist
    • Occupational Therapist
    • Recreational Therapist
    • Speech-Language Pathologist
    • Licensed Social Workers
    • Rehabilitation Trained Mid-Level Providers

ConnectCare

Utilization Management

ConnectCare's Utilization Management Staff is available to address questions and issues related to case management and utilization by using the telephone or fax numbers listed below.

ConnectCare Medical Management
4000 Wellness Drive
Midland, MI 48670
Toll free: 888-646-2429
Local: 989-839-1613
Fax: 989-839-1679
 
Hours of Operation
8:00 a.m. - 12:00 p.m.
1:00 p.m. - 5:00 p.m.
Monday - Friday (Eastern Time)

After normal business hours, inbound communications and information may be relayed via fax, confidential voice mail or electronic mail. All precertification requests and/or communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.