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.
- Beginning Jan. 1, 2020, all home health visits for members with commercial group and individual plans will require prior authorization before the first visit. Historically, these visits did not require authorization for the first 30 home health visits per plan year. Medicare and Medicaid plans already require authorization before the first visit.
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.
Always refer to your Priority Health contract to identify what services will be paid by Priority Health. This is particularly important as it will guide you in understanding if certain ancillary services are your responsibility.
Don't know what your contract covers? Contact your facility administrator for information. Your Priority Health Case Manager does not know the specifics of your contract.
Standard contracted services
All contracts include room, board, skilled services provided by the facility, and drugs. The Jimmo v Sebelius Settlement clarified CMS rules for skilled care and related documentation. See our Jimmo v Sebelius page for details and requirements for home health education.
These services which may or may not be covered under your contract. Check your contract to determine if you are responsible for covering ancillary services such as transportation, dialysis, DME, chemotherapy, etc. If your contract covers these ancillary services, you are not responsible for paying the provider.
If your contract does not cover these ancillary services, you are responsible for paying the service provider. If you get a bill, direct the provider to submit the claim for reimbursement to Priority Health.
See our Ambulance services page for details on how Medicare and MAPD plans cover non-emergent transportation.
If you provide a service that requires prior authorization to an MA/MAPD plan member without first getting authorization, you can't send us an authorization request after the fact. You must submit a Request for payment. See Retrospective authorizations for details.
Appealing coverage for non-covered skilled nursing care
Should the MA/MAPD plan member appeal the termination decision, KEPRO, the Quality Improvement Organization (QIO) for the state of Michigan, notifies Priority Health of the member's appeal. Priority Health - not the home health care services - must then issue a CMS-10124 form, Detailed Explanation of Non-coverage (DENC).
No later than the close of business the day that it is notified of the member appeal, Priority Health must:
- Complete a CMS-10124 form, Detailed Explanation of Non-coverage (DENC), with specific and detailed information about why home health services are ending.
- Send a copy of the form to the Michigan QIO, KEPRO.
- Issue the DENC form to the plan member.
The DENC serves to inform the member of the reason for the coverage termination so he/she has an opportunity to present his/her views to the QIO.
Home health care services may not appeal on behalf of a member unless the home health care services is member's appointed representative; proof may be required by the QIO.
Required appeal information
Be sure to have designated weekend and evening staff responsible for completing required tasks for KEPRO.
Priority Health staff can assist you with questions for after-hours or weekend appeals. Call our on-call nurse at 800.259.1260.
The following information must be faxed to KEPRO:
- History and physical
- Physician orders
- Physician progress notes
- PT evaluation and progress notes
- OT evaluation and progress notes
- ST evaluation and progress notes
- Social service/DC planning notes
- Skilled nursing notes
- Wound care orders and flowsheets
- Face sheet
Fax due dates and times:
- During regular business week/hours: 5:00 p.m. on same day
- After business hours: Noon the next day
- Weekends: 3:00 p.m. Monday
Find more information on Medicare in-home safety assessments and post acute care