Summary of change: Effective April 1, 2019, HealthKeepers, Inc. will require all wound care requests to include current clinical documentation for Anthem HealthKeepers Plus members. This must include clear documentation of medical necessity including history, effectiveness of treatment and plan of care (POC). This affects home health wound care providers, including private duty nurses and skilled home health professionals.

 

What does this mean to me?

 

Requests for wound care services submitted without the documentation listed below may result in delayed or rejected precertification requests.

 

What documentation is required?

 

It is required that a wound care POC includes:

 

Patient information:

 

  • Date the patient was last seen by the PCP or specialist for the wounds
  • The start date of wound treatment
  • Accurate diagnostic information pertaining to the underlying diagnosis and condition
  • Other medical diagnoses and conditions, if applicable, including the patient’s overall health status, for example:
    • Off-loading pressure and glucose control for a patient with a diabetic ulcer
    •  Adequate circulation for a patient who has an arterial ulcer

 

  • Patient’s permitted current and prior functional limitations and activities
  • Nutritional deficits or needs required for patient
  • Dose and frequency of medications

 

Description of wound:

 

  • Wound measurements including length, width, depth, tunneling and undermining
  • Wound color, drainage (type and amount) and odor, if present

 

Wound treatment:

 

  • Describe current prescribed wound care regimen including frequency, duration and supplies needed.
  • Describe all previous wound care therapy regimens, if applicable.
  • If an infection is present, describe the current treatment regimen.
  • If wound debridement is prescribed, documentation must support the level and number of debridements. Documentation should indicate if the debridement involves muscle or bone.
  • Provide evidence of maintaining a clean, moist bed of granulation tissue.

 

Equipment used for wound treatment:

 

  • Pressure-reducing support surface, mattress and/or cushion
  • Compression system (for example, if a patient has a venous ulcer)


A POC must be signed and dated by the physician or accompanied by the physician’s signed and dated orders. The patient must be seen by a physician within 30 days of the initial start of care and at least once every six months thereafter unless the patient’s condition changes.

 

A revised POC is required for every change request in home health visits. The revised POC must include all continuing and new orders. It must also be updated to document any changes in the patient’s condition or diagnosis.

 

What authorization form should I use?

 

The Precertification Request Form located on our provider website at https://mediproviders.anthem.com/va must be used for service requests. It is important that the form is complete with all supporting clinical documentation provided. Requests without the required documentation will be returned as incomplete. Fax requests with the required clinical information to fax number.

 

This PA can also be submitted electronically by logging in to the Availity Portal at https://www.availity.com. You can also view the status of the request after it is submitted.

 

Please note that form CMS 285 will not be accepted.

 

What will I receive after I submit the request?

 

We will fax responses to requests with a reference ID number and determination letter to the servicing provider within three business days of receipt of request.

 

What if I have questions?

 

If you have any questions about this communication, call our Provider Services team at 1‑800‑901‑0020 or call the Anthem CCC Plus team at 1‑855‑323‑4687.



Featured In:
February 2019 Anthem Provider Newsletter - Virginia