Provider Information

Implementation of New Assessment Timeframe

TO: Home Health Agencies

FROM: Christine Gianopoulos, Director, Bureau of Elder and Adult Services

SUBJECT: Implementation of New Assessment Timeframe

DATE:June 23, 2004

Effective July 1, 2004, the Department will implement a new timeframe that Home Health agencies must use for requesting prior authorization for continuing home health services. Under the new procedures, MaineCare members may receive services for two certification periods, up to 120 days, before prior authorization (PA) is required to continue services. (Currently, providers must submit a request for PA in orderfor services to continue beyond one 60-day certification period.)

The procedures for new admissions remain unchanged from current requirements. The Home Health agency must submit to BEAS the member’s admit/start of care form and the 485 plan of care. If the member requires continued services beyond the 60-day certification period, and continues to meet the eligibility requirements in MaineCare Benefits Manual, Chapter II, Section 40.02, Home Health Services, then services may continue for another certification period of up to 60 days.

Providers must follow this new procedure: Within 5 calendar days following the start of the second certification period, the home health agency must submit to BEAS: 1) an updated admit/start of care form and 2) an updated 485 plan of care. The Department no longer requires PA to start a second certification period. BEAS will record another 60 days into the computer system to allow classification to continue and claims to be paid upon receipt of the updated forms. If the member requires continued services beyond 120 days, then the provider must submit a request for prior authorization to Goold Health Systems.

This new prior authorization timeframe applies to nursing services, home health aide services and medical social services. Assessment/management and teach/training remain limited to 120 days. Prior Authorization procedures for the physical therapy, occupational therapy and speech & language therapy services remain unchanged. (These therapy services are limited to 20, 20 and 35 visits per year, respectively, before prior authorization is required in order to continue services.) The prior authorization procedures for psychiatric medication services remain unchanged, requiring PA for any additional disciplines to the psychiatric nursing.

Due to severe budget constraints, the Department must find efficiencies in operating this service, and ensure that any changes are cost-neutral.Therefore, the Department will monitor the discharge rates of members following the implementation of this change in procedures. The Department expects that providers will continue to ensure that members meet the eligibility requirements set forth in Section 40.02. In the event that utilization should increase for this service, the Department will review the procedures and take steps to ensure budget neutrality.

The Department will soon issue proposed rulemaking to incorporate this new timeframe. However, implementation for this policy change shall start on July 1, in accordance with recent legislation, and will be made effective retroactively once rules are in place.

Providers should contact Mollie Baldwin, BEAS, at 287-9200 or Julie Tosswill, BMS at 287-9360 with any questions. Providers may also check the OMS Home Health for the updated process and forms to be used starting July 1,2004.

CC:Vicki Purgavie, Home Care Alliance

Julie Tosswill, Bureau of Medical Services

Mollie Baldwin, Office of Elder Services