Provider Information

Initial Certification for Home Health for Fiscal Year 2002: July 1, 2001 June 30, 2002

Consumers, age 21 years and over, accessing Medicaid Home Health may receive an initial certification period of up to 62 days, or 20 PT, or 20 OT visits, or 35 ST visits, without prior authorization for each state fiscal year, as described in Section 40.02-3D. The initial certification period shall mean any new admission, or any re-admission subsequent to a discharge from HH services. The state fiscal year runs from July 1, 2001to June 30, 2002.

1. What happens at the beginning of the new state fiscal year July 1? Must all HH recipients be reassessed?

New admission: An initial certification period that begins on or after July 1, 2001 does not require prior authorization from Goold, the Assessing Services Agency. Be sure to submit the Admit/Discharge form to OADS for the first certification period that begins after July 1, 2001. Prior authorization is required only if services are to continue beyond this initial certification period into a consecutive certification period.

Current recipients: Any recipient with a current certification would not require prior authorization for their next consecutive certification period because this new certification serves as the initial certification for FY 2002. For example, a recipient whose current certification expires July 7, 2001 would not require prior authorization for the next 62-day certification period. If services are to continue, in this case, beyond September 7, 2001, a timely referral (5 days prior to the end of certification period) for a new assessment is required.

Readmissions: A consumer who has received HH services earlier in the state fiscal year and was discharged, shall not require prior authorization if readmitted. This readmission shall be viewed as a new initial certification period. . Be sure to submit an Admit/Discharge form to OADS for these consumers.

Example #1: .A HH recipient whose current certification expires July 7, 2001 would not require prior authorization for the next 62-day certification period, because this will be the initial certification period in a new SFY. If services are to continue, in this case, beyond September 7, 2001, a timely referral (5 days prior to the end of certification period) for a new assessment is required.

Example #2: Prior authorized eligibility 1/31/01-7/31/01 approved by Goold. Certification periods: 5/1-7/1, 7/1-9/1. While the consumers medical eligibility is valid through 7/31/01, the first certification period after July 1, 2001 requires submission of Admit/Discharge form to OADS. HHA submits this for 7/1/01 to 9/1/01 for initial certification period of FY 2002; no prior authorization is required. The HHA is required to make a referral to Goold 5 days before 9/1/01 for prior authorization if services are to continue and be reimbursed by Medicaid.

Example #3: Certification period of 6/15/01 to 8/15/01. Goold prior authorized eligibility from 2/15/01 to 8/15/01. The period 8/15/01 to 10/15/01 is the initial certification period for SFY 2002. The Admit/Discharge form, received by OADS, from the HHA, for 8/15/01 to 10/15/01, ends the previous PA completed by Goold through 8/15/01. A referral to Goold for prior authorization is required 5 days before 10/15/01 to assure payment if services are to continue and be reimbursed by Medicaid.

Example #4: Consumer prior authorized from 6/1/01 to 8/1/01. Consumer then accesses initial certification from 8/1/10/01/01. Consumer discharged 9/29/01. In January 2002, consumer hospitalized and requires Medicaid HH. HHA may readmit and consumer now begins another initial certification period from January 5, 2002 to March 5, 2002. The HHA is required to make a referral to Goold 5 days before 3/5/2002 for prior authorization if services are to continue and be reimbursed by Medicaid.

2. For consumers accessing the Psychiatric Medication services benefit only:

The current classification period expires for all consumers accessing this category of service on June 30, 2001, the end of the state fiscal year. To continue coverage of Psychiatric Medication services beyond June 30, 2001, by Medicaid Home Health, please send the following to OADS:

  1. A completed Admit/Discharge form with a start-of-care date of July 1, 2001.
  2. A new/updated Section 17 certification for July 1, 2001 See the Aging Website for a copy of the form http://www.maine.gov/dhhs/oads/aging/
  3. The current HCFA 485 that provides the MD signature and service plan, goals, etc. The physician must also certify on the HCFA 485 that the recipients medical condition prevents the safe use of outpatient services and is contraindicated for specific reasons. The reasons must be listed and the likelihood of such a bad result must be probable or definite, as opposed to possible or rarely.

BEAS will carefully review the HCFA 485s to assure that the plan of care, signed by the physician, is for psychiatric services medication administration and monitoring services only, provided by an RN. Please review carefully the eligibility criteria described in Section 40.02-3(C)(3). Counseling and psychotherapy are not covered under this psychiatric medication services only benefit, nor are the assessment of ADLs or adjustment to disease processes and other types of RN intervention. Any HH service in addition to the psychiatric medication services requires prior authorization from Goold.

Example: Psychiatric medication services started July 1, 2000 with an end date of June 30, 2001. Admit/Discharge form, HCFA 485 and Section 17 exemption must be submitted to BEAS as of July 1, 2001.

3. For consumers accessing psychiatric medication benefit and other home health services:

  1. The current classification period expires for all consumers accessing Psychiatric Medication Services whether provided as a stand alone service or in combination with other Medicaid HH services on June 30, 2001, the end of the state fiscal year. To continue coverage of Psychiatric Medication Services beyond June 30, 2001, by Medicaid Home Health, please follow the instructions in #2 above.
  2. Medicaid HH: The prior authorization for the additional home health services ends with the reassessment due date. If at the end of the prior authorized, current classification period Home Health services need to continue, another request must be made to Goold for a prior authorization assessment, at least five days prior to the reassessment due date to assure no gap in Medicaid reimbursement. Any HH services in addition to the psychiatric medication services require prior authorization from Goold.

Example: Psychiatric medication services started July 1, 2000 with an end date of June 30, 2001. Admit/Discharge form, HCFA 485 and Section 17 exemption must be submitted to BEAS as of July 1, 2001. Medicaid HHA services authorized from 6/11/2001 to 8/11/2001. Completed referral packet must be submitted to Goold at least 5 days prior to 8/11/2001 (no later than 8/7/2001) for reassessment to prior authorize HHA if continued services needed.

4. New admissions for initial certification period after July 1, 2001: Follow the standard practice - Send completed Admit/Discharge form and HCFA 485 to OADS.

EFFECTIVE JULY 1, 2001

Until further notice, prior authorization no longer required for consumers who have an authorized POC in place and require adding a new discipline or additional units of service. This applies to initial certification POCs and prior authorized POCs. Prior authorization is required for all disciplines and units of services at the end of the current period of eligibility.

OVERVIEW OF MEDICAID HOME HEALTH PROCESS

WHY is the admission packet required?

Classification codes now exist for Medicaid HH

The home health agency must submit the Admit/Discharge form to OADS anytime there is a new start-of-care or a discharge

The Department must receive the required forms to enter eligibility codes into Welfre

Start and end dates for initial 62 day certification are entered only after ALL required documentation has been received by OADS.

Medicaid financial eligibility is verified

Prevents provision of services to non eligible recipients

Prevents non-covered claims to providers

Claims will not be paid without data entry into Welfre to support compliance with Section 40 policy

When to send updates on Admit/Discharge forms:

Addition of any discipline to a POC during initial certification

Use the same Admit/Discharge form-add new disciplines start date-fax to OADS

Discipline is discontinued, whether during initial or consecutive certification

Use the same Admit/Discharge form-add disciplines end date-fax to OADS

Discharge occurs

Use the same Admit/Discharge form-check off discharge outcome and date-fax to OADS

Prior authorization required when:

The consumer requires continued Medicaid HH services beyond the initial certification into a consecutive certification period.

The consumer is receiving psychiatric medication services and requires any additional HH services of MSW, RN, HH, PT, OT, ST. Prior authorization is required for any additional service (Section 40.02-3(D)(4)).

Prior authorization no longer required for consumers who have an authorized Home Health POC in place and require adding a new discipline or additional units of service, effective July 1,2001.

Referral Packet must be submitted to Goold to request prior authorization

Complete packet includes:

Completed referral form

Referral attachment

HCFA 485 for new certification period

Section 17 exemption when applicable

To avoid gaps in payment submit the above documents at least 5 days prior to the end of the initial certification period or the reassessment due date

Goold will complete the assessment within 5 days of receipt of complete referral packet

Referral is not complete or considered timely until all information is received

Late Notification

Policy requires that referrals for prior authorization and continued medical eligibility must be received 5 days prior to the initial certification end date or reassess due date

If a referral is received less than 5 days prior = late notification = payment lapse

DOS & DONTS

Do Not send referral forms and referral attachments to OADS - this can delay a timely assessment being completed

Do Not send Admit/Discharge forms to Goold- these must go to OADS in order for the classification codes to be entered into Welfre

Do send admission packet and updates to OADS

Do send referral packet to Goold at least 5 days prior to certification end date or reassessment due date.

PROBLEM RESOLUTION

Goold contact 1-800-832-9672

Dianne Postupack - if problems or issues with the assessment occur

OMS contacts

Cheryl Pelletier Provider Relations 287-1773

Julie Tosswill Policy issues 624-5519

OADS contacts

Lorraine Lachapelle or Mollie Baldwin at OADS central office for system issues regarding the assessment process

Payment research when rejected claims indicate classification date problems

Complete payment research form and fax to OADS 624-5365