Below is an overview of CMS regulatory requirements as it relates to the Medicare home care utilization review process. Jefferson Health Plans is now enforcing these requirements for Medicare Advantage members; compliance is necessary to avoid disruptions to prior authorization determinations.

Home Health Services

Please refer to the Provider Manual, Chapter 8, for complete details.

A prior authorization for initial evaluations for home care services is not required. The initial evaluation request, along with the signed NOMNC, must be faxed to 215-967-4491 within five business days of the initial visit to be reimbursed for the initial visit.

Physician orders or prescriptions can be verbally accepted but must be noted and signed as such by a RN. The initial evaluation date must be included in the dates of service on the authorization request. Services cannot be billed without an authorization number for the following services:

•  Skilled nursing (RN/LPN)
•  Infusion therapy
•  Home health aide
•  Physical therapy
•  Occupational therapy
•  Speech therapy
•  Social Work

If further treatment is needed following the initial evaluation, a prior authorization will be required.

Valid home care orders require either:

• VALID verbal signature in 5 days (acceptable clinicians to provide verbal order include RN, NP and PA. It excludes medical assistants, LPNs and receptionists). Home care agency nurses must document the clinician that gave the verbal order, time, and date.

1. Signed POC by certifying practitioner
   1. Certiying practitioner signature expected within 2 weeks
      1. If we receive counter signed verbal order, it will cover through the 30^th day with the expectation that the signed POC would also be received by the 30^th day
      2. If verbal order counter signature is not received by the end of the 2 weeks, services will be denied going forward unless we receive the signed POC
   2. Home care agency must document outreach attempts to obtain the signed POC
   3. Maximum allowed timeframe for signed initial POC will be 30 days
      1. Additional details provided by CMS at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf
         (Section 30.2.6)
   4. Subsequent signed POC required every 60 days
      1. Additional details provided by CMS at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf
         (Section 30.2.7)

Post service requests

• The notice of admission (NOA) must be submitted timely. All HHAs must submit an NOA to Jefferson Health Plans within 5 days of start of care.
• If NOA is not submitted within 5 days of start of care, services prior to receiving the NOA would not be reimbursable.
  • Additional details provided by CMS at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf  (Section 10.4)

Timeframe Requirements

• The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care
  • Additional details provided by CMS at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf (30.5.1.1 – Face-to-Face Encounter)

NOMNC

• Services will only be reimbursable for 48 hours after Jefferson Health Plans has instructed the provider that further services are denied and requested that the member be issued a NOMNC.
• If the provider fails to issue a timely NOMNC, Jefferson Health Plans will not reimburse services that occur 48 hours after the provider has received the denial notification.