Aetna Post-Acute Care Initial Prior Authorization Form 12.24.2025

Sep 17, 2026

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Aetna Post-Acute Care Initial Prior Authorization Form collects eligibility and attestation details for SNF or IRF requests, including benefit verification, admission cause, therapy-note timing, and therapy intensity requirements. The form captures member and facility information such as demographics, policy number, phone, caregiver and residence prior to hospitalization, hospital admission date, expected PAC admission date, ordering physician details, and admitting diagnosis code. It also lists required attachments, including history and physical, discharge summary, clinical progress notes, medication and therapy notes with participation level, and supporting functional assessment items.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Member/Facility Information

Disclaimer and Attestation

Documents to Attach

Assessment Type and Coverage

Requested Service Type (SNF/IRF)

Member Details

Admission Information

Ordering Physician and Diagnosis

| Disclaimer statements and attestation
• Verify eligibility and benefits prior to request. SNF or IRF benefits verified? Yes No If “yes”, number of days available
􀁸 Is the admission a result of a motor-vehicle accident or workplace injury? Yes No
􀁸 Are all therapy notes within 24-48 hours of admission date? Yes No
􀁸 SNF member is receiving at least one hour of therapy five days a week? (only choose one answer) Yes No
􀁸 IRF member is receiving PT or OT at least three hours per day/five days per week and able to sit for one hour per day? (only choose one answer) Yes No
Sign and date here: | | | | | | | --- | --- | --- | --- | --- | --- | | Documents to Attach: History & Physical Discharge Summary (if available) Clinical Progress Notes (for recertification requests)
Medication list Therapy notes including level of participation (evaluation and last progress notes within the last 24-48 hours) | | | | | | | Assessment Type/Coverage | | | | | | | Requested Service Type: SNF IRF | | | | | | | Member/Facility Information | | | | | | | Member Name | | Date of Birth | Member Address | | | | Policy Number | | Member Phone Number | | | Hospital Admission Date | | Requesting Facility Name | | Requesting Facility Address | | | | | Requesting Facility Phone Number | | Requesting Facility Fax number | | | Requesting Facility Contact Name | | Servicing Facility Name | | Servicing Facility Address | | | | | Servicing Facility Phone | | Servicing Facility Contact Name (if known) | | | Servicing Facility NPI (Required) | | Member Information | | | | | | | Primary Caregiver | | Contact Number | | Child Spouse Friend Self
Paid caregiver | | | Residence Prior to Admission to Hospital: Lives alone Lives with family Lives with paid caregiver Homeless Shelter
Assisted living facility Long term care/NH | | | | | | | Admission Information | | | | | | | Expected Admission
Date to PAC facility | Ordering Physician | Ordering Physician Address/Phone Number | | | Admitting Diagnosis Code | | Along with this form, please submit the following (if applicable) with your prior authorization request. Any missing required information could result in an unnecessary delay or potential denial:
Prior and current level of functioning
PT/OT evaluation/progress notes within the last 24-48 hours
Ambulation: \# of feet /Assist device used
Ability to perform ADL’s
Bed Mobility
Transfers
Toileting transfers
Gait/Distance
Number of steps at home/level of assistance needed
Wound details: Wound size, location, treatments
Complete Medication List
SNF level requested (if applicable) | | | | | | Aetna Page 1 of 1

FAQs

What eligibility and attestation checks are required before submitting the request?

Verify eligibility and benefits prior to the request. Confirm whether SNF or IRF benefits are verified, the admission resulted from a motor-vehicle accident or workplace injury, and that all therapy notes are within 24–48 hours of the admission date.

What therapy-related requirements must be met for SNF and IRF requests?

For SNF, confirm the member is receiving at least one hour of therapy five days a week. For IRF, confirm PT or OT is provided at least three hours per day/five days per week and the member can sit for one hour per day.

What documents and supporting information should be attached with the prior authorization request?

Attach history & physical and discharge summary (if available), clinical progress notes for recertification requests, medication list, and therapy notes including level of participation with evaluation and last progress notes within the last 24–48 hours. Also submit prior/current level of functioning and relevant PT/OT evaluation/progress notes, plus functional and care details such as ambulation, ADLs, bed mobility, transfers, toileting transfers, gait/distance, wound details, and complete medication list.

Sep 17, 2026

Upload by Bintang