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September 2016 CSHCN Services Program Provider Manual

21 Home Health Services : Benefits, Limitations, and Authorization Requirements : Prior Authorization Requirements for Home Health Services : Authorization Requirements

21.2.1.1 Authorization Requirements
Prior authorization of home health services is required. Medical necessity documentation must be submitted along with the prior authorization request. Requests may be submitted by any approved method to the claims administrator.
Verbal orders will not be accepted. All prior authorization requests must be signed and dated by the ordering practitioner.
Prior authorization must be obtained before the start of care however, if the service is medically necessary, provided after hours or on a recognized holiday or weekend, services may be authorized when the request is submitted on the next business day. A completed CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form and all other required documentation must be received within these deadlines for prior authorization to be considered. Extensions to these deadlines are not given by the CSHCN Services Program for providers to correct incomplete prior authorization requests.
Note: An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign and date all documentation related to the provision of SN, HHA, or extended skilled nursing services on behalf of the client’s physician when the physician delegates this authority to the APRN or PA.
SN services or HHA services (procedure codes G0156, G0299, and G0300) will not be authorized during the same period of time as extended SN services (S9123 and S9124).
SN Services or HHA Services (procedure codes G0156, G0299, and G0300) will not be considered for authorization during the same period that the client is receiving extended SN services (procedure codes S9123 and S9124). The request for SN or HHA Services, when extended SN services are already authorized will be reviewed by the CSHCN Services Program Medical Director before a denial is issued.
Extended SN Services (procedure codes S9123 and S9124) will not be considered for prior authorization during the same period that the client is receiving SN or HHA services (procedure codes G0156, G0299, and G0300). The request for extended SN services, when SN or HHA services are already authorized will be reviewed by the CSHCN Services Program Medical Director before a denial is issued.
The initial nursing assessment is used to establish the POC and must support the medical necessity for the client to receive SN services, HHA services, extended SN services, PT services, OT services, social work services, speech-language pathology services, or medical nutritional counseling services. The provider must have an RN perform an initial client assessment or reassessment in the client’s home. For initial prior authorization, providers must obtain prior authorization before the start of care (SOC). Initial prior authorization period may not exceed 60 calendar days.
Note: The initial RN assessment is an administrative cost and will not be reimbursed.
The initial nursing assessment/reassessments must include, but are not limited to the following:
The initial assessment and any reassessments are performed by an RN. The initial assessment must be completed no earlier than three business days before the client’s SOC. Reassessments are required when changes in the client’s condition occur during the course of the prior authorization period and revision of the plan of care is needed. Revisions to the POC must be submitted as soon as the need is identified but no later than 3 business days from the date of the revision.
If there is no change in the client’s condition, the reassessment must document medical necessity, as defined in the Statement of Benefits, to support continued and ongoing acute, intermittent, part-time SN or HHA visits services beyond the initial 60 calendar day prior authorization period. Requests received after the three business days allowed will be denied for dates of service that occurred before the revision is approved.
For extension of acute intermittent, part-time SN or HHA services, providers must obtain prior authorization on the CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form before the end of the current prior authorization period. A new client assessment and a current POC must also be submitted. Extension requests that are received after the current prior authorization expires will be denied for dates of service that occur before the extension request is approved.

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