Authorization and Prior Authorization List Changes

Home Health Preauthorization Process

EFFECTIVE 10/01/2019, Updated for 1/1/2023 – HealthTeam Advantage UM will authorize home health based on medical necessity and CMS criteria. Please reference home health request types 1-4 listed below for home health service preauthorization requests.

Home Health request type 1
New referral from PCP or attending provider
7-Day Grace Period
Acute Care Hospital Stay

***A new request for home health services must be submitted after every inpatient stay (a new authorization number will be received for each separate request).  HH visits authorized before the hospitalization will not be valid for visits provided after the hospital stay.   If the stay is observation, the existing authorized visits may be used.

Must include:

• HTA-UM prior authorization request form
• Physician order and/or hospital order (verbal order acceptable, provider signature optional)
• Supporting clinical documentation as applicable

A standard request consists of the visits listed to the right of each service type:

• Skilled Nursing (SN) – 7 visits/60-day cert period
• Therapy services:
• Any combination of therapy totaling 6 visits per 60-day cert period.
  • Physical Therapy (PT)
  • Occupational Therapy (OT)
  • Speech Therapy (ST)
• ** Example: PT 2 visits, OT 3 visits, and ST 1 visit.  Total combination = 6 visits.
  • Medical Social Worker (MSW) – 1 visit for the evaluation
  • Home Health Aide (HHA) – 9 visits/60 days

Note: If a request exceeds the standards listed above, additional clinical information must be provided to support the need for more time or visits.

Home Health request type 2
New referral from PCP (or other physician) NOT following an acute care hospital stay.  7-day grace period OR PTS Standard, PTS Expedited
Includes POST SNF stay

Must include:

• HTA-UM prior authorization form
• Physician order and/or hospital order (verbal order acceptable, provider signature optional)
• Supporting clinical documentation as applicable

A standard request consists of the visits listed to the right of each service type:

• SN – one visit for evaluation
• Therapy services:
  • PT – one visit for evaluation
  • OT – one visit for evaluation
  • ST – one visit for evaluation
• MSW – one visit for evaluation

Home Health request type 3
Request for additional visits within the same 60 certification period.
We will provide a new authorization for additional visits requested (if approved) during a certification period.

NO Grace Period – submit before services being rendered

Must include:

• HTA-UM prior authorization request form
• 485 form – Must be submitted for all subsequent requests for additional visits.

A request for additional visits should follow the guidelines below for each service:

• SN visits – must have supporting documentation for skilled need.
• Wound care – must include wound locations, measurements, and description. Wound care order and frequency must be included in request.
• Coumadin therapy – must include PT/INR values, Coumadin adjustments, and frequency.
• Insulin administration – must include frequency, blood sugars, and dosing. Must include the reason why patient is unable to self-administer and efforts to locate alternative sources for long-term need.
• Therapy visits – must have PT, OT, and/or ST evaluation included. Patients being discharged home from a rehabilitation facility (acute rehabilitation facility or sub-acute rehabilitation facility) will be reviewed and compared with level of function documented at time of rehab discharge. Please provide a document with a summary of prior level of functioning, current level of functional ability, and goals.
• Therapy requests exceeding 6 visits at week three will need to submit a new therapy evaluation to support medical necessity of additional therapy visits.
• MSW – must include evaluation note and plan for continued visits.
• Home Health Aide (HHA) visits – skilled care request should support patient need for HHA to assist with personal care needs. If needed long term, request should state who will be providing the service.

Home Health request type 4
Request for additional visits beyond the initial 60-day certification period.
A new authorization will continue to be generated and approved if meets medical necessity.  Note: HH requests extended into additional certification periods are automatically reviewed by our medical director to assess for custodial versus skilled services.

NO Grace Period – must be submitted PTS Standard or PTS Expedited

Must include:

• HTA-UM prior authorization request form
• 485 form – Must be submitted for all subsequent requests for additional visits. Please provide new referral request and 485 form at least one week in advance of existing approval expiration.

A request for additional visits should follow the guidelines below for each service:

• SN visits – must have supporting documentation for skilled need.
• Wound care – must include wound locations, measurements, and description. Wound care order and frequency must be included in request.
• Coumadin therapy – must include PT/INR values, Coumadin adjustments, and frequency.
• Insulin administration – must include frequency, blood sugars, and dosing. Must include reason why patient is unable to self-administer and efforts to locate alternative sources for long-term need.
• Therapy visits – must have PT, OT, and/or ST evaluation included. Patients being discharged home from a rehabilitation facility (acute rehabilitation facility or sub-acute rehabilitation facility) will be reviewed and compared with level of function documented at time of rehab discharge. Please provide a document with a summary of prior level of functioning, current level of functional ability, and goals.
• Therapy requests exceeding 6 visits at week three will need to submit a new therapy evaluation to support medical necessity of additional therapy visits.
• MSW – must include evaluation notes and plan for continued visits.
• Home Health Aide (HHA) visits – skilled care requests should support patient needs for HHA to assist with personal care needs. If needed long term, request should state who will be providing the service.

RETRO AUTHORIZATIONS WILL BE ADMINISTRATIVELY DENIED.
IN-NETWORK PROVIDERS MAY NOT BALANCE BILL MEMBERS.
You have claim dispute options.

• How to Submit a Claim Dispute:
  • Send dispute letter to include the following:
  • Member Name
  • ID Number
  • Claim Number
  • Detailed explanation of the dispute and supporting documentation
• Mailing Address:
  • HealthTeam Advantage Claims Department
    P.O. Box 652
    Southborough, MA 01772
• Faxed Requests are Not Accepted