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
- 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 EmblemHealth 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.
The requesting provider should be prepared to submit:
- Appropriate eviCore request form - available at: https://www.evicore.com/resources/healthplan/emblemhealth
- Patient’s medical records
- Details such as:
- 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
||Methods to Submit Prior Approval Requests
||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 EmblemHealth 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 EmblemHealth, then option 4.
||Call (800) 877-7587 or fax your request to (888) 746-6433.
||Call (888) 666-8326.
Prior Approval Time Frames
eviCore will provide Prior Approval by service type in the following ways:
||Home Health Aide Social Worker
||7 calendar days
||7 calendar days
||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 EmblemHealth, 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.
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.
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.