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  • Home Health Care > Prior Approval Process

    Services Requiring Prior Approval

    EmblemHealth will continue to manage Personal Care Assistants (PCA) and Consumer Directed Personal Assistance Program (CDPAP). See Care Management chapter.

    eviCore healthcare (eviCore) will begin accepting prior approval requests for services on December 28, 2017 for dates of service beginning January 1, 2018 for the following HHC Services:

    • Skilled Nursing
    • PT/OT/ST
    • Social Worker
    • Home Health Aides (for members receiving skilled HHC services)

    Who Requests Prior Approval

    • SNF, IRF and LTAC are responsible for submitting the initial Home Health Service requests for all HIP members discharging from a PAC facility with home health services.
    • HHC agencies will submit prior approval requests to eviCore for hospital discharges and community referrals.

    How To Obtain a Prior Approval
    All providers must verify member eligibility and benefits prior to rendering services at emblemhealth.com/Providers. The following sections describe the information you will need to submit to eviCore and the processes for submitting prior approval requests.

    Required Information

    The requesting provider should be prepared to submit:

    • Appropriate eviCore request form - available at: evicore.com/healthplan/emblem
    • Patient’s medical records
    • Details such as:
      • Background
        • Site of Care demographics
        • Patient demographics
        • Services requested (Skilled Nursing/OT/PT/ST/SW/HHA)
        • Home Health ordering physician demographics
        • Anticipated date of discharge

      • Clinical Information
        • PAC admitting diagnosis and ICD10 code
        • Clinical Progress Notes & Oasis Assessment
        • Medication list
        • Wound or Incision/location and stage (if applicable)
        • Discharge summary (when available)

      • Mobility & Functional Status
        • Prior and Current level of functioning
        • Focused therapy goals: PT/OT/ST
        • Therapy progress notes including level of participation
        • Discharge plans (include discharge barriers, if applicable)

    How to Obtain Prior Approval
    Managing Entity Methods to Submit Prior Approval Requests
    eviCore eviCore offers three convenient methods to request prior approval, depending on the Program:

    1. Web Portal submissions are the most efficient way to request prior approvals. Please visit evicore.com/pages/providerlogin.aspx.

    2. Telephone: Clinical information can be called in to eviCore healthcare at 866-417-2345, choose option 3 for HIP members; then option 4 DME and prompt 1 for CPAP and BIPAP or 2 for other DME services.

    3. Facsimile: DME required documentation can be faxed to 866-663-7740.

    For DME requests prior to January 1, 2018, fax to 1-866-426-1509. On or after, December 28, 2017,submit requests to eviCore for anticipated dates of service on or after January 1, 2018.

    DME Suppliers may obtain prior approval details via the eviCore web portal at: evicore.com/pages/providerlogin.aspx or by calling eviCore at: 866-417-2345, option 3 for HIP, then option 4.
    HealthCare Partners Call (800) 877-7587 or fax your request to (888) 746-6433.
    Montefiore CMO Call (888) 666-8326.

    Prior Approval Time Frames
    eviCore will provide Prior Approval by service type in the following ways:

    Prior approval Skilled Nursing Home Health Aide  Social Worker PT/OT/ST
    Initial 7 calendar days N/A 7 calendar days
    Concurrent 14 calendar days 14 calendar days 14 calendar days

    Once clinical information is received, determinations will be made within 1 business day. If a peer to peer review is requested, add an additional business day. However, eviCore’s typical response time is less.

    Once determination is made, eviCore will provide verbal and written notification to the requesting facility or HHC Agency. The servicing HHC agencies may obtain prior approval details by calling eviCore at 866-417-2345, option 3 for HIP, then 5 for Home Health Care or Transitional Care; then either 1 for Home Health Care or 3 for Transitional Care.

    Initial prior approval is valid for 7 days. During that timeframe, the services must be initiated or new prior approval is required.

    Home Health Care Prior Approval Criteria

    Criteria used by eviCore includes, but is not limited to:

    • McKesson InterQual® Criteria
    • Medicare Benefit Policy Manual Chapter 7 Section 30.1,
    • Evidence-Based Tools along with Clinical Findings.

    Retrospective Reviews
    eviCore will accept requests for retrospective reviews for medical necessity. Requests must be submitted within 14 calendar days from the date the initial service was rendered.

    Discharge Planning
    The discharge planning process should begin as early as possible. This allows time to arrange appropriate resources for the member's care.

    From Home Care: Once the patient is discharged from the HHC agency, the PCP will be notified by eviCore.

    From a Hospital: HHC agencies are responsible for submitting prior approval requests to eviCore for hospital discharges. For post-acute care services, (acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment), the eviCore concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services. Patients utilizing HHC services following a hospitalization will be managed by eviCore’s Transitional Care Program for 90 days post hospital discharge.

    From a SNF, IRF or LTAC: The discharging facility is responsible for submitting the initial Home Health Service requests.

    Notice of Medicare Non-Coverage (NOMNC) for Medicare Members
    Important: For date extension (concurrent review) prior approval requests, HHC Agencies should submit clinical information 72 hours prior to the last covered day. This allows time for Notice of Medicare Non-Coverage (NOMNC) to be issued. eviCore will issue the NOMNC form to the provider. The provider is responsible for issuing the NOMNC to the member, having it signed and returning it to eviCore.

    In accordance with CMS guidelines, the Notice of Medicare Non-Coverage (NOMNC) will be issued by the servicing provider no later than 2 calendar days before the discontinuation of coverage, if care is not being provided daily.

    If the member is cognitively impaired, the servicing provider is responsible for informing the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date it, the staff member and witness who informed the proxy of the end date and appeal rights should sign and date the form, then fax it back to eviCore or send via the eviCore PAC Web Portal.

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    Glossary terms found on this page:

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

    • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
    • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
    • It is in accordance with accepted standards of good medical practice in the community.
    • It is furnished in a setting commensurate with the member's medical needs and condition.
    • It cannot be omitted under the standards referenced above.
    • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
    • It is not furnished primarily for the convenience of the member, the member's family or the provider.
    • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

    The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

    Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The physician or other provider who specifically prescribes the health care service being reviewed.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

    A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.

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