Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingNovember 11, 2024
Home health utilization management process
Submitting a non-waiver home health (HH) prior authorization (PA) for all health plans (Hoosier Care Connect, Healthy Indiana Plan, Hoosier Healthwise, and Indiana PathWays for Aging) can be done via:
- Availity Essentials.
- Outpatient utilization management (UM) direct fax line 844-765-5157.
- Indiana Health Coverage Program (IHCP) PA form fax number 866-406-2803.
Initial HH services:
- Documentation required for a new (initial) skilled nurse (SN), home health aide (HHA), and or home therapy PA request:
- The IHCP PA form
- Enter the requesting provider as the physician, nurse practitioner, or physician assistant who signs the HH plan of care (POC)
- The POC (we will accept the copy of the POC; then the provider must send the signed POC within 15 to 30 days)
- Face-to-face attestation
- Supporting clinical as a medical necessity review will be applied
Continuity of care (COC) for all plans:
- Documentation required for COC PA requests:
- The IHCP PA form
- Enter the requesting provider as the physician, nurse practitioner, or physician assistant who signs the HH plan of care (POC)
- The previous fee-for-service (FFS) or managed care entity (MCE) approval letter that lists the units and dates of service (DOS) approved
- The face-to-face attestation
- Medical necessity review is not applied for COC PAs.
- The COC period is from the date the member became active with us to 90 days (for example, July 1 through September 28).
- Units will be adjusted to the 90-day date of service.
- If the previous FFS or MCE approval letter ends before 90 days, then the end date is entered into the UM system, and the units are adjusted accordingly:
- For example, the COC PA was approved from April 1 through July 31. Our end date will be July 31. Units are adjusted accordingly.
- Out-of-network PAs are honored for all health plans for COC for IHCP-attested providers.
Ongoing subsequent HH services (initial or COC services are completed):
- Submit the next PA no sooner than 14 to 30 days before the previous authorization expires.
- Documentation required for each subsequent PA if services need to continue:
- Submit the IHCP PA form.
- The POC (we will accept the copy of the POC, then the provider must send the signed POC within 15 to 30 days).
- Any supporting clinical as a medical necessity review will be conducted.
- Face-to-face is not required for established HH services.
- If there is a break in HH service 30 days or greater a new face-to-face is required.
The medical necessity decision will be completed within five business days (excluding weekends and state-approved holidays) from the date the request was received.
If any of the above information is missing from the fax or the Availity Essentials case for any service requested, the provider will receive a returned fax or an external Availity Essentials note to submit the missing information. The five-business day turnaround starts when all required documentation is received.
If member changes HH providers:
- The new HH provider must submit the following:
- IHCP PA form
- POC
- Any supporting clinical
- The HH agency that will no longer render service must send:
- The discharge note to UM.
- Then UM will update the initial HH case to end the DOS when the member is discharged from the initial HH agency.
General HH information
Effective January 1, 2025, we will allow a six-month date for service for HH PA requests for Indiana PathWays for Aging. All other plans will continue to follow the below dates of service.
Date of service for standard hourly HH services are granted for 60 days (if approved per medical necessity). This follows the HH per-cert period.
Private duty SN and HHA are granted (if approved per medical necessity) in 90-day intervals.
We allow a seven-calendar day grace period for the provider to send the HH PA:
- For example, member admits to HH on July 15. The PA must be submitted with the required documentation by July 22 (seven calendar days)
For CPT® code 99600 PA requests, a medical necessity review is applied to the request. The PA request must meet medical necessity criteria for the requested hours. We use non-customized MCG as per the state contract.
Medical benefit for 99600 does not cover custodial HHA services. Custodial care is covered under the applicable waiver service, such as personal attendant care.
If a medical necessity denial or a partial denial of services is rendered, the denial letter contains and explains the post denial options. Follow the process defined in the appeal rights enclosure within the denial letter.
For assistance with questions regarding the PA requirements, please call Provider Services for the membership plan listed below:
- Hoosier Healthwise — 866-408-6132
- Healthy Indiana Plan — 844-533-1995
- Hoosier Care Connect — 844-284-1798
- Indiana PathWays for Aging — 833-569-4739
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.
INBCBS-CD-071235-24
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