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24.5.4 Home Health Skilled Nursing and Home Health Aide Services Prior Authorization Requirements
SN services and HHA visits require prior authorization. Requests must be submitted by fax or in writing by mail. Providers must obtain authorization within three business days of the SOC date for an initial authorization. For recertifications, providers must obtain authorization within seven business days of the new SOC date. During the authorization process, providers are required to deliver the requested services from the SOC date which is the date agreed to by the physician, the RN, the home health agency, and the client, parent, guardian, or caregiver. The SOC must be documented on the POC. A provider requesting prior authorization for SN and/or HHA Services must submit the following documentation:
• A completed client assessment.
•A completed Texas Medicaid Home Health Services POC that must:
•Be signed and dated by the assessing RN.
•Signed and dated by the physician or submitted with the signed and dated physician's orders.
Prior authorization of SN or HHA visits requires that a client's primary care physician complete the following steps:
•Provide specific, written, dated orders for SN or home health agency visits or recertification that identifies that the prescribed visits are medically necessary as defined in the Statement of Benefits.
•Maintain documentation in the client's medical record that supports the medical necessity of the prescribed visits.
•Maintain documentation in the client's medical record that demonstrates that the client's medical condition is sufficiently stable to permit safe delivery of the prescribed visits as described in the client's Home Health Services POC.
•Establish a medical plan of care that is maintained in the client's medical record.
•Provide continuing care and medical supervision.
•Review and approve the client's Home Health Services POC once every 60 days or more frequently as the physician determines necessary, including but not limited to a change in the client's condition.
All signatures must be current, unaltered, original, and handwritten; computerized or stamped signatures will not be accepted. All documentation, including all written and verbal orders, and all physician-signed POCs, must be maintained by the ordering physician, and the home health agency must keep the original, signed copy of the POC in the client's medical record.
Requests must be based on the medical needs of the client. Documentation must support the quantity and frequency of intermittent or part-time SN and/or HHA visits that will safely meet the client's needs. The amount and duration of SN and/or HHA visits requested will be evaluated by the claims administrator. The home health agency must ensure the requested services are supported by the client assessment, POC, and the physician's orders.
The length of the authorization is determined on an individual basis and is based on the goals and timelines identified by the physician, home health agency, RN, and client, parent, guardian, or caregiver. SN and HHA visits will be prior authorized for no more than 60 days at a time. As a client's problems are resolved and goals are met, a client's condition is expected to become more stable, and the client's needs for SN and HHA services may decrease.
SN visits to obtain routine laboratory specimens may be considered when the only alternative to obtain the specimen is to transport the client by ambulance. SN visits to address hyperbilirubinemia will not be considered for prior authorization if the client has an open authorization for home phototherapy. Home phototherapy is reimbursed as a daily global fee and includes coverage of SN visits for client or parent, caregiver teaching and monitoring, and customary and routine laboratory work.
SN visits to address total parenteral nutrition (TPN)/hyperalimentation will not be considered for prior authorization if the client has an open authorization for TPN/hyperalimentation. TPN/hyperalimentation is reimbursed as a daily global fee and includes coverage of SN visits for client, parent, or caregiver teaching and monitoring, customary and routine laboratory work, and enteral supplies and equipment.
Up to a maximum combined total of three SN and HHA visits may be prior authorized per day. One visit may last up to a maximum of 2.5 hours. SN and/or HHA visits may be provided on consecutive days.
When documentation does not support medical necessity for home health SN and/or HHA visits, providers may be directed to possible alternative services based on the client's age and needs.
A prior authorization for SN and/or HHA visits is no longer valid when:
•The client is no longer eligible for Medicaid.
•The client no longer meets the medical necessity criteria for SN and/or HHA services.
•The place of service cannot provide for the health and safety of the client.
•The client, parent, guardian, or caregiver refuses to comply with the attending physician's plan of treatment and compliance is necessary to ensure the health and safety of the client.
•The client changes providers and the change of notification is submitted to the claims administrator in writing with a prior authorization request from the new provider.
A nurse/HHA may be authorized to provide services to more than one client over the span of the day as long as each client's care is based on an individualized POC and each client's needs and POC do not overlap with another client's needs and POC. Settings in which a nurse/HHA provider may provide services in a provider-client ratio greater than 1:1 include, but are not limited to, homes with more than one client receiving home health services, foster homes, and independent living arrangements.
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