Provider Information

Home Health update

Below are highlights of the MaineCare Home Health procedures effective July 1, 2004:

Psychiatric Medication Services Only:  Current members’ classification for psychiatric medication services ends June 30,2004. Admission paperwork is required every July 1st of each fiscal year for members eligible to continue to receive this service category.

An admit form, most recent 485 and annual Section 17 certification must be submitted to BEAS if services are going to continue. BEAS will update the classification up to 365 days in the computer system to allow reimbursement to continue upon receipt of the updated forms.

The Behavioral and Developmental Services’ MaineCare Section 17 Client Certification Form must be completed on each member on an annual basis, and must accompany the member’s admission paperwork each fiscal year.

17.02-4.1 Determination of Eligibility. For each member seeking community support services, a designated community support provider will:

B. Determine the member’s eligibility, initially and annually, for community support services, and complete the appropriate verification of eligibility form provided by BDS. The annual verification must include a recent diagnosis as documented by an appropriately licensed professional.

 Any additional discipline(s) requires Prior Authorization (PA) from Goold Health Systems before payment will be approved, for members being served under the Section 17 exemption.

Effective July 1, 2004, home health agencies may serve members meeting the eligibility requirements for Section 40, MaineCare Home Health for up to 120 days before PA is required from GHS.

 Home health agencies must submit member’s admission home health paperwork (Admit Form, 485 and reason out-patient services are contraindicated) to BEAS within 14 days of admission

Ø If a member currently receiving Section 40 Home Health Services has a certification end date prior to July 1, 2004, a referral to GHS for PA is required if continued eligibility and services are required.

§  Example: Initial certification of April 25, 2004 to June 25,2004.  If member meets the eligibility criteria and requires continued services, refer to Goold for prior authorization.

Ø If a member currently receiving Section 40 Home Health Services has a certification end date after July 1, 2004, and meets the medical eligibility and requires continued services, follow the procedure below.

§ Example: Initial certification of May 25, 2004 to July 25, 2004.  If member meets the eligibility criteria and requires continued services up to another 60 day certification period may be accessed without PA.  At the end of that 60-day certification (total 120 days) if member meets the eligibility criteria and requires continued services, refer to Goold for prior authorization.

New Procedure:  If the member requires a 2nd Certification Period, the agency must submit re-certification paperwork (Admit Form, 485 for the 2nd Cert Period and reason out-patient services are contraindicated) to BEAS within 5 calendar days following the start of the second certification period.  Indicate if the paperwork is for the 1st or 2nd Certification Period, by checking the appropriate box on the revised Admit Form.  Enter the services that are being delivered as certified by the physician.  Enter the start date for each of those services.  If disciplines have been added or discontinued between the 1st and the 2nd Cert Period, make the corrections as appropriate, on the Admit Form for the 2nd Cert Period.  The member’s medical condition must require skilled services on a part-time or intermittent basis, or otherwise no less than twice per month. 

  • Assessment/Management for a chronic condition is only a covered service for 120 days per admission.

Ø If member has had 120 days when PA is requested, assessment management can no longer be authorized for additional certification periods unless the member’s needs meet the “Unstable” definition as defined in Section 40.01-20.

Teaching/Training is only a covered service for 120 days per admission.  If member has had 120 days of teaching/training do not request PA for this service as the maximum allowed has been accessed.

Feel free to call either Lorraine Lachapelle or myself at 287-9200 or 1-800-262-2232.

 

CC:  Julie Tosswill, Bureau of Medical Services

        Michelle Quintal, Bureau of Medical Services

        Lorraine Lachapelle, BEAS