405 IAC 5-16-3 - Prior authorization for home health agency services; generally
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
(a) All home
health services require prior authorization by the office, except the
following:
(1) Services provided by a
registered nurse, licensed practical nurse, or home health aide, which have
been ordered in writing by a physician prior to the patient's discharge from a
hospital, and that do not exceed one hundred twenty (120) units within thirty
(30) calendar days of discharge from a hospital. These services may not
continue beyond thirty (30) calendar days unless prior authorization is
received.
(2) Any combination of
therapy services ordered in writing by a provider in accordance with
405 IAC 5-22-6(b)(1)
prior to the patient's discharge from a
hospital and that do not exceed thirty (30) units within thirty (30) calendar
days of discharge from a hospital. These services may not continue beyond
thirty (30) calendar days unless prior authorization is
received.
(b) Prior
authorization requests for home health agency services may be submitted by an
authorized representative of the home health agency. Written prior
authorization forms must contain the information specified in
405 IAC 5-3-5. Telephone requests
for the prior authorization of services will be conducted in accordance with
405 IAC 5-3-2 and
405 IAC 5-3-6.
(c) The following information must be
submitted with the written prior authorization request form and may also be
requested as written documentation to supplement telephone requests for prior
authorization:
(1) Copy of the written plan
of treatment, signed by the attending physician.
(2) Estimate of the costs for the required
services as ordered by the physician and set out in the written plan of
treatment. The cost estimate must be provided on or with the plan of treatment
and signed by the attending physician.
(3) Documentation of a face-to-face encounter
in accordance with 42 CFR
440.70(f) is
required.
(d) Prior
authorization will include consideration of the following, if applicable:
(1) Review of the information provided in the
written Medicaid prior review and authorization form, or telephone request for
prior authorization, and any additional required or requested
documentation.
(2) Review of the
following factors when determining the appropriate services, units of service,
and length of period for prior authorized services for home care members:
(A) Severity of illness and
symptoms.
(B) Stability of the
condition and symptoms.
(C) Change
in medical condition that affects the type or units of service that can be
authorized.
(D) Treatment plan,
including identified goals.
(E)
Intensity of care required to meet needs.
(F) Complexity of needs.
(G) Amount of time required to complete
treatment tasks.
(H) Rehabilitation
potential.
(I) Whether the services
required in the current care plan are consistent with prior care
plans.
(J) Need for instructing the
member on self-care techniques in the home or need for instructing the
caregiver on caring for the member in the home, or both.
(K) Other caregiving services received by the
member, including, but not limited to, services provided by Medicare, Medicaid
Waiver Programs, CHOICE, vocational rehabilitation, and private insurance
programs.
(L) Caregivers available
to provide care for the member, including consideration of the following:
(i) Number of caregivers available.
(ii) Whether the caregiver works outside the
home.
(iii) Whether the caregiver
attends school outside of the home.
(iv) Reasonably predictable or long term
physical limitations of the caregiver that limit the ability of the caregiver
to provide care to the member.
(v)
Whether the caregiver has additional child care responsibilities.
(vi) How and when the units of service
requested will be used to assist the caregiver in meeting the member's medical
needs.
(M) Whether the
member works or attends school outside of the home, including what assistance
is required.
(N) Special situations
when additional home health units may be authorized on a short term basis,
including the following:
(i) Significant
deterioration in the condition of the member, particularly if additional units
will prevent an inpatient or extended inpatient hospital admission.
(ii) Major illness or injury of the caregiver
with expectation of recovery, including, but not limited to:
(AA) illness or injury that requires an
inpatient acute care stay;
(BB)
chemotherapy or radiation treatments; or
(CC) a broken limb, which would impair the
caregiver's ability to lift the member.
(iii) Temporary, but significant, change in
the home situation, including, but not limited to:
(AA) a caregiver's call to military duty;
or
(BB) temporary unavailability due
to employment responsibilities.
(iv) Significant permanent change in the home
situation, including, but not limited to, death or divorce with loss of a
caregiver. Additional units of service may be authorized to assist in providing
a transition.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.