Home health and post-acute care

We've introduced new prior authorization guidelines and InterQual® criteria for home health visits. Using InterQual® criteria will ensure the services our members receive align with the most current standards of care and best practices. We're confident that using InterQual® criteria will provide consistent, standardized, and evidenced-based guidance.

  • As of Dec. 1, 2018, any prior authorizations requests for home health care will be subject to InterQual® criteria to ensure appropriate, quality care for all product lines.
  • As of Jan. 1, 2019, all home health visits for Medicare and Medicaid members will require prior authorization before the first visit and will be subject to InterQual® criteria, Medicare guidelines, or the Medicaid provider manual.  All commercial products will continue to be subject to InterQual® criteria for any prior authorization beyond 30 visits.

For training resources on how to enter an authorization using our Clear Coverage prior authorization tool, view the recorded webinars.

Medicare coverage education for providers

If you provide skilled nursing facility care, skilled home care services and/or skilled physical, occupational and speech therapy to Medicare beneficiaries, then you're required to understand the issues of the Jimmo v Sebelius case and the resulting Jimmo Settlement Agreement on coverage.

Learn more on our Jimmo Settlement Agreement page.

Home health care services forms