Floor to in-network skilled nursing facility inpatient prior authorization process

As a reminder, Anthem requires the documentation of PASRR (Preadmission Screening and Resident Review) form for initial and concurrent stay prior authorization requests to an in-network skilled nursing facility (SNF) for Ohio Medicaid Managed Care members.

Floor to in-network SNF inpatient prior authorization process requires that the nursing facility and provider must be in-network; member needs to have a 6-click score of 18 or below (physical and occupational therapy) and the member must not have any exclusions:

• Transfer from an acute rehab facility
• Transfer from a long-term acute care hospital (LTACH) facility
• Transfer from a psychiatric/geropsychiatric hospital unit
• Member whose prior level of function (PLOF) is non-ambulatory
• Member has been admitted to a hospital from a SNF or acute rehabilitation facility
• Member was denied an LTACH admission
• Member was denied a standard SNF precertification request

Referring provider/facility or SNF is required to submit the SNF/Rehab Worksheet and PASRR (Preadmission Screening and Resident Review) form in the initial 24 hr. therapy evaluation period and clinical information within three business days after the date of admission to aid in members’ care coordination, discharge planning, and member management. Documentation listed is required before final determination is made by Anthem.

If the member does not qualify for the Floor to SNF prior authorization, the referring provider/facility must go through the standard pre-certification process.

PASRR regulations (Ohio Administrative Code Rule 5160-3-14) require that all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payer source, be assessed for indications of serious mental illness and/or a developmental disability unless the member meets requirements for a Hospital Exemption.

For your convenience, the PASRR form can be downloaded here.

Anthem will conduct random audits and monitor trends to evaluate the effectiveness of this initiative.

Refer to the frequently asked questions (FAQ) below for more information.

Frequently asked questions

As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required within 48 hours or next business day of admission. However, you can notify Anthem of the admission and may move a member to the SNF without authorization if they meet the six clicks and floor to SNF requirements. It will be important to verify member benefits and submit a PASRR form. For additional details on our Floor to SNF prior authorization process or visit our provider portal at Availity.com.

When do I need to submit clinical information?

For the initial SNF admission, submit the clinical information no later than three business days after the admission, and for continued stay, prior to the last covered day.

Does this apply to SNF, inpatient (IP) rehab, and long-term acute care (LTAC) admissions?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP rehab and LTAC.

For the SNF initial authorization of seven days, will Anthem assign a level of care?

Anthem utilization management will assign level of care once the PASRR and clinical information is received from the SNF.

If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility and physician both need to be in-network. All out-of-network facilities and providers must follow the standard prior authorization process.

Contact us

Availity Chat with Anthem is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.