Services Requiring Preauthorization
EmblemHealth 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 and process you need for submitting preauthorization requests.
The requesting provider should be prepared to submit:
- 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 and Outcome and Assessment Information Set (Oasis)
- Medicine list
- Wound or incision/location and stage (if applicable)
- Discharge summary (when available)
- Mobility and 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)
EmblemHealth offers two (2) convenient methods to request preauthorization – online (fastest option), and by phone. See the Who to Contact for Preauthorization section of the Directory chapter.
Preauthorization Time Frames
Once determination is made, EmblemHealth 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 EmblemHealth include, but are not limited to:
- MCG Health (fka Milliman Care Guidelines)
- Medicare Benefit Policy Manual Chapter 7 Section 30.1
- Evidence-based tools along with clinical findings
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, the HHC agency should notify the primary care provider (PCP).
From a Hospital: HHC agencies are responsible for submitting preauthorization requests to EmblemHealth for hospital discharges.
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 before the second to last covered visit, but no less than 72 hours prior to that visit. This allows time to issue the Notice of Medicare Non-Coverage (NOMNC). The provider is responsible for completing and issuing the NOMNC to the member, having it signed and returning it to EmblemHealth. If the provider issues a NOMNC during a period where the member is authorized, the provider should notify EmblemHealth as soon as possible and submit a copy of the notice.
In accordance with Centers for Medicare & Medicaid Services (CMS) guidelines, the servicing provider issues the NOMNC no later than two (2) 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 the health care proxy of the end-of-service dates and the appeal rights for members who are cognitively impaired. 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, document that the form was reviewed verbally with the proxy, and return it to EmblemHealth.