Try for free

Massachusetts SNF/Rehab/LTACH Prior Authorization Form

Massachusetts' standard form requests authorization, or initial precertification, for admission to a skilled nursing facility, rehabilitation hospital or long-term acute care hospital. It is used when a patient is moving from an acute hospital or home to post-acute care under a Massachusetts insured plan. The receiving facility and referring physician details, clinical status, prior function, home setup and discharge plan go to the health plan.

Who completes it

The referring acute facility's case manager and the receiving facility complete it together: Section B names the receiving facility, its attending MD and the referring MD (acute attending, PCP or specialist), and Sections D to H carry the clinical, functional and home details.

Submitting and payment

How to submit it
Send the completed form to the patient's health plan before the anticipated admission date, attaching additional clinical information to Section E where needed.

Good to know

  • Do not use it for physical, occupational or speech therapy for members in long-term care; it covers SNF/TCU, acute rehab, IRF and LTACH admissions.
  • Section C asks whether PASRR screening is complete, and Section E covers oxygen, trach, ventilator settings and weaning plan, wounds, tube feeding, TPN, IV therapy and dialysis.
  • Sections F and G record prior level of function and the prior home environment, including stairs, ramps, rails, bathroom and bedroom floor, support hours and equipment.
  • Members who need ambulance transport must use a participating ambulance provider. The current version is dated September 2025.

Get the official form

Download the current version from the source each time; forms change without notice.

Massachusetts Standard Form for Initial SNF/Rehab/LTACH Prior Authorization Requests

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What does the Massachusetts post-acute prior authorization form cover?

It requests authorization or initial precertification for skilled nursing, long-term care hospital or rehabilitation hospital services, with place-of-service choices of SNF/TCU, acute rehab, LTACH or IRF. It is not for physical, occupational or speech therapy for members in long-term care.

Which clinical details does the Massachusetts SNF/Rehab/LTACH form ask for?

Section E covers mental status, pain, oxygen, trach and ventilator needs, suctioning, wounds, tube feeding, TPN, IV therapy, lab monitoring, dialysis, mobility and ADL assistance levels, speech and swallowing needs, and whether post-acute PT, OT or ST is required.