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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 3 Home Health Skilled Nursing and Home Health Aide Services : 3.4 * Authorization Requirements : 3.4.2 * Home Health Services Plan of Care Requirements

3.4.2
The initial assessment or reassessments are used to establish and revise the home health services POC and must support the client’s medical necessity for SN services, HHA services, PT services, and OT services.
Note:
Providers must use the Texas Medicaid home health services POC located on the TMHP Prior Authorization Texas Medicaid Forms web page; the Centers of Medicare and Medicaid (CMS) Form 485 will not be accepted.
The POC must be initiated and written in a clear and legible format by the RN and include the following:
List all community or state agency services the client receives in the home including, but not limited to, primary home care (PHC), community based alternative (CBA), medically dependent children’s program (MDCP)
Documentation of coordination with PPECC, when a client receives ongoing skilled nursing in a PPECC setting. When a client receives PPECC, the SN and/or HHA provider must provide a medical rationale to support the need for SN and/or HHA services, when PPECC services are provided on the same day.
The POC must be accompanied by the physician’s signed and dated orders or must be signed and dated by the physician. The POC must include the SOC date (when the services will begin) and must be signed and dated by the assessing RN.
When a provider has received signed physician orders for SN or HHA visits, the POC does not require a physician signature before the provider contacts the claims administrator for prior authorization of services. The POC must be signed and dated by a physician familiar with the client prior to submitting a claim for services, and no later than 30 days from the SOC date.
The type and frequency of visits, supplies, or DME must appear in the POC before the physician signs the POC and may not be added after the physician has signed the POC. If any change in the POC occurs during a prior authorization period (additional visits, supplies, or DME), the provider must update the POC, have the physician sign the updated POC, and contact the claims administrator for prior authorization.
Note:
Verbal physician orders may only be given to people authorized to receive them under state and federal law. They must be reduced to writing, signed and dated by the RN or qualified therapist responsible for furnishing or supervising the ordered service. The physician must sign the written copy of the verbal order within two weeks, or per agency policy if less than two weeks. A copy of the written verbal order must be maintained in the client’s medical record prior to and after being signed by the physician.
Note:
All documentation, including all written and verbal orders, and all physician-signed POCs, must be maintained by the physician, and the home health agency must keep the original, signed copy of the POC in the client’s medical record.
The client must be seen by a physician within 30 days of the initial SOC, and at least once every six months thereafter unless the client’s condition changes.
Note:
The physician visit may be waived when a diagnosis has already been established by the physician, and the client is under the continuing care and medical supervision of the physician. A waiver is valid for no more than 365 days, and the client must be seen by his or her physician at least once every 365 days. The waiver must be based on the physician’s written statement that an additional evaluation visit is not medically necessary. This documentation must be maintained by the physician and the provider in the client’s medical record.
A revised POC is required for every request for any change in SN or HHA visits. The revised POC must include all continuing and new orders. The revised POC must be updated to document any changes in the client’s condition or diagnosis.
A new POC is required with every request for recertification. The new POC must include all continuing and new orders. The new POC must document all changes in the client’s condition or diagnosis and reflect the need for continued SN or HHA services in relation to the original need for care. The physician must certify he or she has provided continuing care and medical supervision including, but not limited to, examination or treatment of the client within six months or when the client’s condition has changed.

Texas Medicaid & Healthcare Partnership
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