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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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/aetna-post-acute-care-initial-prior-authorization-form-12242025/288467/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/aetna-post-acute-care-initial-prior-authorization-form-12242025/288467.png","ImageObject",442,249,{"name":88,"@type":89},"Bintang","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What eligibility and attestation checks are required before submitting the request?","Question",{"text":108,"@type":109},"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.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What therapy-related requirements must be met for SNF and IRF requests?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"What documents and supporting information should be attached with the prior authorization request?",{"text":117,"@type":109},"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.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288467,1789633517,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},962085564381,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","| Disclaimer statements and attestation\u003Cbr>• Verify eligibility and benefits prior to request. SNF or IRF benefits verified? Yes No If “yes”, number of days available \u003Cbr>􀁸 Is the admission a result of a motor-vehicle accident or workplace injury? Yes No\u003Cbr>􀁸 Are all therapy notes within 24-48 hours of admission date? Yes No\u003Cbr>􀁸 SNF member is receiving at least one hour of therapy five days a week? (only choose one answer) Yes No\u003Cbr>􀁸 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\u003Cbr>Sign and date here:   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Documents to Attach: History & Physical Discharge Summary (if available) Clinical Progress Notes (for recertification requests)\u003Cbr>Medication list Therapy notes including level of participation (evaluation and last progress notes within the last 24-48 hours) |  |  |  |  |  |\n| Assessment Type/Coverage |  |  |  |  |  |\n| Requested Service Type: SNF IRF |  |  |  |  |  |\n| Member/Facility Information |  |  |  |  |  |\n| Member Name |  | Date of Birth | Member Address |  |  |\n| Policy Number |  | Member Phone Number |  |  | Hospital Admission Date |\n| Requesting Facility Name |  | Requesting Facility Address |  |  |  |\n| Requesting Facility Phone Number |  | Requesting Facility Fax number |  |  | Requesting Facility Contact Name |\n| Servicing Facility Name |  | Servicing Facility Address |  |  |  |\n| Servicing Facility Phone |  | Servicing Facility Contact Name (if known) |  |  | Servicing Facility NPI (Required) |\n| Member Information |  |  |  |  |  |\n| Primary Caregiver |  | Contact Number |  | Child Spouse Friend Self\u003Cbr>Paid caregiver |  |\n| Residence Prior to Admission to Hospital: Lives alone Lives with family Lives with paid caregiver Homeless Shelter\u003Cbr>Assisted living facility Long term care/NH |  |  |  |  |  |\n| Admission Information |  |  |  |  |  |\n| Expected Admission\u003Cbr>Date to PAC facility | Ordering Physician | Ordering Physician Address/Phone Number |  |  | Admitting Diagnosis Code |\n| 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:\u003Cbr>Prior and current level of functioning\u003Cbr>PT/OT evaluation/progress notes within the last 24-48 hours\u003Cbr>Ambulation: \\# of feet /Assist device used\u003Cbr>Ability to perform ADL’s\u003Cbr>Bed Mobility\u003Cbr>Transfers\u003Cbr>Toileting transfers\u003Cbr>Gait/Distance\u003Cbr>Number of steps at home/level of assistance needed\u003Cbr>Wound details: Wound size, location, treatments\u003Cbr>Complete Medication List\u003Cbr>SNF level requested (if applicable)   |  |  |  |  |  |\n\nAetna Page 1 of 1","cbCaibLjSP5GKcbK","https://ap.wps.com/l/cbCaibLjSP5GKcbK","pdf",1216355,"English","# Member/Facility Information\n## Disclaimer and Attestation\n## Documents to Attach\n# Assessment Type and Coverage\n## Requested Service Type (SNF/IRF)\n# Member Details\n# Admission Information\n## Ordering Physician and Diagnosis","[{\"question\":\"What eligibility and attestation checks are required before submitting the request?\",\"answer\":\"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.\"},{\"question\":\"What therapy-related requirements must be met for SNF and IRF requests?\",\"answer\":\"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.\"},{\"question\":\"What documents and supporting information should be attached with the prior authorization request?\",\"answer\":\"Attach history \\u0026 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.\"}]","Aetna Post-Acute Care Initial Prior Authorization Form 12.24.2025 | PDF"]