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MA PAP307

Home Health Prior Authorizations


Provider Administrative Policy

Section
Prior Authorizations
Policy Date
November 2009
Status/Date
Revised/November 2010

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Home Health Prior Authorizations

Initial Home Health Services Request - From an inpatient setting
Blue Cross of Idaho case managers work with inpatient hospital utilization review and the physician to agree on a member's home health needs prior to discharge. The case manager approves services as agreed upon and Blue Cross of Idaho's Medical Management department generates a letter of preauthorization approval. We may request explanation if the home health agency request does not match our case manager's approval.

Initial Home Health Services Request - From a physician office
Blue Cross of Idaho requires the following from the patient's home health agency:

  • A completed Medicare Advantage Prior Authorization Request form
  • Physician's order
  • Documentation that patient has seen his/her physician in the last 90 days prior to start of care or 30 days after the start of care.

Note that we approve six visits upon submission of the above documentation but only two without documentation.
Additional visit request and/or recertification request

Blue Cross of Idaho requires the following from the patient's home health agency:

  • A completed Medicare Advantage Prior Authorization Request form
  • Physician's order
  • Initial evaluation and goals with measurable progress (Degrees/percentage/level of function/measurements, etc). Please use the  Home Health Update form.

How to submit home health service requests

  • Submit requests online at bcidaho.com. See MAPAP300 or MAPAP301 if online access is not available.
  • Fax requests to the number listed on Medicare Advantage Prior Authorization Request form.
  • Home Health Agency Responsibilities
    If an agency accepts a referral and later determines they are unable to meet the patient's needs, they must:

    • Contact the member and provide information on alternate home health agencies.
    • Contact the alternate home health agency.
    • Notify Blue Cross of Idaho's Medical Management department of the change prior to transfer.

    General Information
    Because documented functional progress is required for continued visits, we only allow requests for six additional visits per service. Call Blue Cross of Idaho to provide justification when requesting more or reducing from six visits per service. 

    We make determinations for home health services based on agency provided documentation and CMS guidelines. 

    See MAPAP102 for contact information.


Policy History

Date Action Reason
November 2010 Revised Policy rewritten for clarity
April 2010 Revised Home health update form added

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