Sub-Acute Rehab (Sar) Prior Authorization Form - Priority Health

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Sub-Acute Rehab (SAR) Prior Authorization/Review Form

All Priority Health Products

Fax form to: 616 975-8848

Reset Form

**Please fax each patient request separately**

Note:

Pg 1 of 2 - Must be completed legibly by all facilities requesting authorization for SAR.

Pg 2 of 2 - Must be completed legibly for all patients admitted to SNF facilities that do not have a Priority

Health onsite case manager. Please note page 2 must be completed upon admission, review, and at

discharge (see details at the bottom of this page) to ensure accurate authorization of days for payment

purposes. Please complete all fields to ensure timely processing.

Member Information:

Name:

Plan Type/Product:

Priority Health ID#:

DOB:

___________________

Transfer from:

Previous Setting

Hospital / Facility Name:

Check box if admitting to SAR from  ED  Observation  Home

Admit to:

Admit date to SAR: ___________________

SAR facility name: ________________________________________________________________

SAR facility tax id (required): ___________________

Admitting diagnosis(s)/ICD code: ____________________________________________________

Please check box if stay is a  swing bed

SAR Facility Information

(please be sure to include the City)

Address: _____________________________ City: ___________________ Zip code: _________

SAR facility contact name: _________________________________________________________

Phone:

Fax: _______________________________

Anticipated discharge date:

Actual discharge date:

Nursing Notes (if needed):

Prior to admit: Complete as much of the form (pg 1 & 2) as possible. Level of function information is required to

determine if patient meets skilled criteria for therapy. If criteria met, 5 days will be authorized. Please include H&P if

possible. If H&P is not available, it must be submitted with the first review.

Concurrent reviews: Fill out the form completely (pg 1 & 2). No additional documentation is required.

Upon discharge: Fill out the form completely (pg 1 & 2) based on discharge from therapy. Please include the therapy

minutes log and discharge summary with this form.

This facsimile transmission contains confidential information. The information is intended solely for use by the individual entity named as the recipient

hereof. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this transmission is

prohibited. If you have received this transmission in error, please notify us by telephone immediately so we may arrange to retrieve this transmission

at no cost to you.

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March 2014