Home Health Care Providers
These resources have been put together for HPSM home health providers.
Patients qualify for home health care services if they are:
- Active HPSM member
- Under the care and under an established plan of care reviewed by a physician or allowed practitioner
- In need of skilled nursing, physical therapy, occupational therapy and/or speech therapy
Required Supporting Clinical Information
To qualify a member for home health care services, you must submit these documents:
- For an initial request, submit a Narrative Report/Summary of SOC Visit
- For a re-authorization request (recertification), submit a Narrative Report/Summary of Recertification Visit
- Recertification visit is done during the last five days of the previous certification period
Unique authorization rules apply for some home health care services. All services requiring prior authorization must be authorized before providing the service except for services that are necessary on an emergent or truly urgent basis.
Please note that authorizations are created per certification period.
- For the most updated prior authorization required list, please visit our Prior Authorizations page.
- Complete and submit a Prior Authorization Request Form
We ask that providers submit requests according to the clinical need/clinical presentation of the member based on assessment. A correction request is appropriate when the following have been identified:
- A change in condition (including a new event requiring skilled care)
- The treating practitioner has ordered a change in treatment and frequency
Hospital Discharge Orders
Please coordinate and confirm with the referral source that orders have been received and the start of care visit will be scheduled within a reasonable time after hospital discharge. This should alleviate duplicative start of care visits.
We encourage providers to submit initial requests within seven calendar days from the start of care visit. Utilization Management (UM) is unable to make corrections on denied authorizations.
Caring For Homebound Members
To request home care visits:
- Visit the HPSM member to start care and conduct an assessment within 48 hours of receiving a physician’s order.
- After the start of care visit has been conducted, compose a care plan for the entire 60 day certification period:
- The care plan should contain any services already delivered (at least the start of care visit, but possibly more) and those future services that will be required.
- Services delivered within the initial 10 calendar day period (counting from start of care visit date of service) will be authorized.
- Any services delivered from calendar day 11 to day 60 of the certification period will be subject to full utilization review and potentially denied if not deemed medically necessary by HPSM staff.
- Fax the request form to HPSM within seven days from start of care. Failure to do so risks denial of some or all services (including those already delivered). Fax should include the following documents:
Providers are encouraged to submit their prior authorization requests to ensure timely clinical review and reimbursement.