PA Lookup

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.

Unit Value

1 visit

Limits

Covered only when provided in a setting in which normal life activities take place; not in a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities, except limited ICF/IID circumstances allowed by policy.

Visits are provided on a per-visit basis.

If multiple services are required and can be performed during the same visit, all services must be completed in only one visit.

Skilled nursing and home health aide services combined must total less than 8 hours per day and 28 or fewer hours per week; based on need, the weekly total may be increased case-by-case to up to 35 hours.

Home health aide services are limited to the amount, frequency, and duration ordered by the physician and documented in the plan of care.

• - Home health aide services are limited to 100 total visits per beneficiary per year.

Exclusions

Home health aide services are not covered when they were not ordered by a physician and included on the authorized plan of care or verbal order. They are not covered when there is no evidence that home health services are the most appropriate setting for the service, when there is no supporting clinical or progress-note documentation signed and dated in accordance with accepted professional standards, or when the service duplicates another provider's service. Home health aide services are also not covered for services related to a terminal illness when the beneficiary has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. In coordination with private duty nursing, home health aide services are not covered on the same day as PDN services.

Place of Service

Covered only in settings where normal life activities take place; not in a hospital, nursing facility, ICF/IID except as specified, or any setting where Medicaid inpatient payment including room and board is or could be made.

Additional Service Specifics

The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 3A
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.

Unit Value

1 visit

Limits

Skilled nursing is provided on a per-visit basis.

Visits are limited to the amount, frequency, and duration authorized by the attending physician and documented in the plan of care.

Visits must be provided on a part-time or intermittent basis.

Part-time or intermittent means skilled nursing and home health aide services combined total less than 8 hours per day and 28 or fewer hours per week; on a case-by-case basis, the weekly total may be increased up to 35 hours.

Pre-filling insulin syringes/Medi-Planner visits are limited to a maximum of every 2 weeks, with 1 PRN visit allowed each month.

Skilled nursing visits are limited to 75 total visits per beneficiary per year.

If multiple services can be performed during the same visit, they must be completed in only one visit.

Exclusions

Skilled nursing is not covered when: it is not ordered by a physician and included on the authorized plan of care or verbal order; there is no evidence that home health services are the most appropriate setting for the service; documentation in clinical or progress notes does not support that the service was provided in accordance with policy and the plan of care; the service duplicates another provider's service; the service is experimental, investigational, or part of a clinical trial; or the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, although unrelated home health services may still be provided. Home health skilled nursing is not covered on the same day as private duty nursing services. Skilled nursing is also not covered for provision of drug infusion therapy when the beneficiary is receiving services from a Medicaid Home Infusion Therapy provider, though home health skilled nursing may be covered for medical needs unrelated to the drug therapy.

Place of Service

Covered only in settings where normal life activities take place; not in a hospital, nursing facility, ICF/IID except as specified, or any setting where Medicaid inpatient payment including room and board is or could be made.

Additional Service Specifics

The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 3A
• Records Management and Documentation Manual

Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.

Unit Value

1 visit

Limits

Skilled nursing is provided on a per-visit basis.

Visits are limited to the amount, frequency, and duration authorized by the attending physician and documented in the plan of care.

Visits must be provided on a part-time or intermittent basis.

Part-time or intermittent means skilled nursing and home health aide services combined total less than 8 hours per day and 28 or fewer hours per week; on a case-by-case basis, the weekly total may be increased up to 35 hours.

Pre-filling insulin syringes/Medi-Planner visits are limited to a maximum of every 2 weeks, with 1 PRN visit allowed each month.

Skilled nursing visits are limited to 75 total visits per beneficiary per year.

If multiple services can be performed during the same visit, they must be completed in only one visit.

Exclusions

Skilled nursing is not covered when: it is not ordered by a physician and included on the authorized plan of care or verbal order; there is no evidence that home health services are the most appropriate setting for the service; documentation in clinical or progress notes does not support that the service was provided in accordance with policy and the plan of care; the service duplicates another provider's service; the service is experimental, investigational, or part of a clinical trial; or the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, although unrelated home health services may still be provided. Home health skilled nursing is not covered on the same day as private duty nursing services. Skilled nursing is also not covered for provision of drug infusion therapy when the beneficiary is receiving services from a Medicaid Home Infusion Therapy provider, though home health skilled nursing may be covered for medical needs unrelated to the drug therapy.

Place of Service

Covered only in settings where normal life activities take place; not in a hospital, nursing facility, ICF/IID except as specified, or any setting where Medicaid inpatient payment including room and board is or could be made.

Additional Service Specifics

The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 3A
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.

Unit Value

1 visit

Limits

Skilled nursing is provided on a per-visit basis.

Visits are limited to the amount, frequency, and duration authorized by the attending physician and documented in the plan of care.

Visits must be provided on a part-time or intermittent basis.

Part-time or intermittent means skilled nursing and home health aide services combined total less than 8 hours per day and 28 or fewer hours per week; on a case-by-case basis, the weekly total may be increased up to 35 hours.

Pre-filling insulin syringes/Medi-Planner visits are limited to a maximum of every 2 weeks, with 1 PRN visit allowed each month.

Skilled nursing visits are limited to 75 total visits per beneficiary per year.

If multiple services can be performed during the same visit, they must be completed in only one visit.

Exclusions

Skilled nursing is not covered when: it is not ordered by a physician and included on the authorized plan of care or verbal order; there is no evidence that home health services are the most appropriate setting for the service; documentation in clinical or progress notes does not support that the service was provided in accordance with policy and the plan of care; the service duplicates another provider's service; the service is experimental, investigational, or part of a clinical trial; or the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, although unrelated home health services may still be provided. Home health skilled nursing is not covered on the same day as private duty nursing services. Skilled nursing is also not covered for provision of drug infusion therapy when the beneficiary is receiving services from a Medicaid Home Infusion Therapy provider, though home health skilled nursing may be covered for medical needs unrelated to the drug therapy.

Place of Service

Covered only in settings where normal life activities take place; not in a hospital, nursing facility, ICF/IID except as specified, or any setting where Medicaid inpatient payment including room and board is or could be made.

Additional Service Specifics

The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 3A
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

• https://www1.radmd.com/all-health-plans/trillium-health-resources
• Trillium iTransact Portal