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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 : 3.4.3 Prior Authorization of SN and HHA Services

3.4.3
Prior authorization requests may be submitted to the TMHP Prior Authorization Department by mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures. For additional information about electronic signatures, please refer to the ’Electronic Signatures in Prior Authorizations’ medical policy.
Home Health SN and HHA services require prior authorization. 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 or HHA Services must submit the following documentation:
Note:
To complete the prior authorization process by paper, the SN or HHA provider must fax or mail the completed documentation to the Home Health prior authorization unit and retain a copy of the signed and dated documentation in the client’s medical record at the provider’s place of business.
Note:
To complete the prior authorization process electronically, the SN or HHA provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated documentation in the client’s medical record at the provider’s place of business.
Note:
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 or HHA visits that will safely meet the client’s needs. The amount and duration of SN 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.

Texas Medicaid & Healthcare Partnership
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