Helpful Hints for Home Health Authorization Request

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Obtaining an Initial Authorization:

Home health providers may obtain initial authorization by calling the home health precertification line. All calls are generally returned within two business days.

• After Hours/Weekends Policy:  When leaving a message, please leave a return phone number, along with the member’s ID number and services requested.
• The agency must make the initial visit prior to calling in to the Home Health precertification line.
• Passport Advantage (PAD) should be notified within three business days of the initial visit (start of care).
• Authorization dates for PAD will be consistent with the “episode of care” dates.
• The PAD authorization covers all services the member needs during the 60-day episode of care.  Authorizations are not given on a per visit basis. 

Adhering to CMS Guidelines:

PAD utilizes the Centers for Medicare & Medicaid Services (CMS) guidelines for home health services.

• The member must be homebound and a skilled service must be present.
• If after the initial visit the member does not meet CMS criteria for home health visits, the Plan must be notified the next business day.

Initial Requests

For initial authorization to be obtained, please have the Oasis available.  PAD will need to know the following:

• Why is the member homebound?
• What is the skilled service(s) being provided?
• Does the member live alone?
• Why is each discipline in the home?
• What is the frequency for each discipline?
• Why is the care needed (medical necessity of visits)?

Recertification Requests

• Recertification requests may be called in or faxed in.
• When requests are faxed in, if enough clinical information is not provided, the agency will be contacted by phone to complete the recertification process.
• Recertification dates will match the agency’s recertification dates based on the Home Health Plan of Care Form 485. 
• If a discipline is added that would normally increase CMS’ PPS payment, then PAD must be notified. Please fax in this information, along with the clinical reason why the discipline is being added. The agency would still need to complete the Oasis paperwork as required by CMS.
• PAD utilizes CMS recertification guidelines.

Infusion Services

• PAD only covers home infusion services that are a covered Medicare Part B benefit in the home.  This list includes pain management for cancer diagnosis, anti-fungals, chemotherapy agents, desferal for iron overload, inotropic therapy, IVIG, TPN and enterals.  All of these medications must meet the CMS guidelines for coverage. 
• Authorizations for nursing visits for the infusion services listed above will be issued to the home health agency under an “episode of care” as long as the member is homebound.
• Infusion services that were not a covered Part B benefit in the home are to be covered by the Part D benefit that is administered by PerformRx.
• Supplies for the Part D drugs are to be directly billed to PAD.