Home Health Care

03/30/2021

This program applies to home health care (HHC) services for EmblemHealth’s companies, Health Insurance Plan of Greater New York (HIP) and EmblemHealth Insurance Company (formerly HIP Insurance Company of New York (HIPIC)). eviCore healthcare (eviCore) manages most HHC preauthorization for these members.

Preauthorization may be needed before certain services can be rendered. Depending on which networks members access and who has financial risk for their care, preauthorization requests are evaluated by either the HHC vendor (eviCore), EmblemHealth, or a Managing Entity. For the list of services requiring preauthorization, refer to Clinical Corner.

HHC must be provided by a contracted HHC provider. To locate an appropriate HHC provider for a patient, visit emblemhealth.com/find-a-doctor.

Preauthorizations do not guarantee claims payment. Services must be covered by the member’s health plan and the member must be eligible at the time services are rendered. Claims submitted may be subject to benefit denial.Prior to rendering services, all providers must verify member eligibility and benefits by signing in to emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab.

Excluded Services

EmblemHealth manages personal care assistants (PCAs) and Consumer Directed Personal Assistance Programs (CDPAPs). See the Utilization and Care Management chapter of the Provider Manual for applicable rules for these services.

Excluded Members

The following are not managed by eviCore:

EmblemHealth Plan, Inc. (formerly GHI) benefit plans
Members whose ID card indicates a primary care physician from one of the following Managing Entities:
- HealthCare Partners (HCP)
- Montefiore CMO (CMO)

Excluded members are medically managed in the same way as they are for other services by the assigned Managing Entity. To determine the Managing Entity, check the member’s ID card or eligibility information by signing in to emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab. See the Utilization and Care Management chapter of the Provider Manual for applicable rules and preauthorization processes. You may also use the Preauthorization Lookup Tool on the provider portal to determine if a preauthorization is required and who is responsible for conducting the review.

Transitional Care Services

eviCore provides transitional care services for members (except those described above under ‘Excluded Members’) discharging from the hospital with HHC services. Members are managed by the eviCore Transitional Care Program for 90 days post-hospital discharge. The Transitional Care Program facilitates member support based on identified risk factors. Core services include primary care physician (PCP) appointment scheduling, disease coaching, social services support, and member education. If the member’s HHC services extend beyond 90 days, EmblemHealth handles utilization management and preauthorization. Refer to the Utilization and Care Management chapter.

Preauthorization Process

Services Requiring Preauthorization

eviCore performs preauthorization review for the following HHC services:

Skilled Nursing (SN)
Physical Therapy (PT)
Occupational Therapy (OT)
Speech Therapy (ST)
Social Worker (SW)
Home Health Aides ((HHAs) for members receiving skilled HHC services)

Who Requests Preauthorization

Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), and Long-Term Acute Care facilities (LTACs) are responsible for submitting:
- The initial HHC service requests for members discharging from a post-acute care (PAC) facility with home health services
HHC agencies may submit preauthorization requests for:
- Hospital discharges
- Community referrals

How to Obtain a Preauthorization

Below is the information you need and the process for submitting preauthorization requests to eviCore.

The requesting provider should be prepared to submit:

The appropriate eviCore request form
Patient’s medical records
Details such as:
- Background
  - Site of care demographics
  - Patient demographics
  - Services requested (SN/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)

eviCore offers three (3) convenient methods to request preauthorization:

Online: evicore.com/provider
Phone: 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.
Fax: 855-488-6275

Preauthorization Time Frames

eviCore provides preauthorization for set periods of time by service type in the following ways:

Preauthorization	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

Home Health Authorization Period

What will be authorized

Bundle

Initial authorization 4 SN 4 PT up to 40 HHA x 4 weeks

All cases

Initial request must include documentation of medical necessity and homebound status needed within the submitted clinical information, if additional visits are required above those approved, clinical information must be submitted prior to completing the visits.

Concurrent review requests will remain at 14 days

# visits will be based on medical necessity.

Once clinical information is received, determinations are made within one (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 provides verbal and written notification to the requesting facility or HHC agency. Initial preauthorization is valid for seven (7) days. During that time, services must be initiated, or a new preauthorization is required.

Home Health Care Preauthorization Criteria

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

MCG Health (fka Milliman Care Guidelines) – for cases on and after Sept. 1, 2020
McKesson InterQual^® Criteria – for cases prior to and including Aug. 1, 2020
Medicare Benefit Policy Manual Chapter 7 Section 30.1
Evidence-Based Tools along with Clinical Findings

Retrospective Reviews

eviCore accepts 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, eviCore notifies the PCP.

From a Hospital: HHC agencies are responsible for submitting preauthorization requests to eviCore for hospital discharges. For PAC services (acute rehabilitation, skilled nursing facility stay, home care, and durable medical equipment), the eviCore concurrent review nurse facilitates preauthorizations of medically necessary treatments if the member’s benefit plan includes these services.

From an 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) requests, HHC agencies should submit clinical information 72 hours prior to the last covered day. This allows time to issue the Notice of Medicare Non-Coverage (NOMNC). eviCore issues 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 servicing provider issues the NOMNC no later than two calendar days before the discontinuation of coverage if care is not being provided daily. The following calendar day after services end is not covered unless an adverse determination is overturned or the NOMNC is withdrawn.

The servicing provider is responsible for informing members who are cognitively impaired of the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date the NOMNC, 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.

Denial and Appeals Process

Denial of Preauthorization

Cases that do not meet medical necessity on initial nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potentially adverse determination, the requesting provider is contacted and offered a peer-to-peer (P2P) review.

P2P must be requested within one business day or a denial letter is issued. Any additional clinical information that supports medical necessity must be received within one business day. If not, the determination is final, and the case is closed.

If the P2P process does not result in a reversal of the denial, eviCore issues a denial letter. The physician reviewer may suggest an alternate level of care and/or the appeals process. Once a service is denied, members and providers must file an appeal to have the request reviewed again.

Denial to Extend Services

Cases that do not meet medical necessity on concurrent nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potential adverse determination, the requesting HHC agency is contacted and offered a P2P as described above.

Reconsideration Process (Commercial and Medicaid only)

A reconsideration is a post-denial, pre-appeal opportunity to provide additional clinical information. Reconsideration (P2P) must be requested within 14 days of the initial denial date. P2P requests can be made verbally or in writing. P2P is conducted with the referring physician and one of eviCore’s Medical Directors. P2P results in either a reversal or an uphold of the original decision. The requestor and the member are notified via mail and fax.

Appeals Process (Medicare, Medicaid, and Commercial)

Once a service has been denied, members and providers must file an appeal to have the request re-reviewed.

Medicaid or Commercial members requesting to appeal a denial for HHC services should follow the instructions provided on the denial letter. Providers should submit appeal requests to eviCore via phone at 800-835-7064 (Monday through Friday, 8 a.m. - 6 p.m.) or fax at 866-699-8128.
·Medicare members may request an appeal of a denial for HHC services by following the instructions provided in the denial letter. Providers should follow the process in the Dispute Resolution for Medicare Plans chapter of the EmblemHealth Provider Manual.

Turnaround time after an appeal has been requested by the member is as follows:

Expedited: up to 72 hours
Standard: up to 30 days

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