SNF/Acute Rehab/LTAC – Initial Request ONLY

Member Information

Enter Member Id and Date of Birth and click Submit below to validate the member and fetch Member Details.

Member ID*

Member DOB*

Member Name*

First Last

Error Field

Provider Information

Requesting Facility/Provider Name*

Contact Name*

First Last

Contact Phone #*

Contact Fax #*

Email Address*

In order to receive confirmation of receipt request

Name of Ordering Physician*

First Last

Date of Admission to SNF/Acute Rehab/LTAC (If Known)

Level of Care*

Please note: When submitting an initial authorization request for Skilled Nursing Facility (custodial or skilled) level of care, a Preadmission Screening and Resident Review (PASRR) is required. Please submit a copy of the completed PASRR Level I to support the authorization request.

Level of Care *

SNF Skilled
SNF Custodial
Acute Rehab
LTAC

Is this a transfer between facilities?*

Is this a transfer between facilities? *

Yes
No

Accepting Facility (If Known and Different From Requesting Facility)

Accepting Facility NPI (If Known)

Clinical Information

Diagnosis (Click + or - at the right to add additional Diagnoses)*

Diagnosis	ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890

Purpose of Referral*

Rehab Therapy (PT, OT, ST)
Skilled Nursing (IV, meds/Complex wound care, etc)
Respiratory -Vent, Trach
Custodial, non-skilled services

Please include any important documents of medical necessity for the requested level of care such as rehab evaluation, skilled or non-skilled needs, progress notes, discharge planning notes.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 23 MB.

Additional Comments

Agreement*

Authorization is not a guarantee of payment

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