| Plan type | Authorization guidelines |
|---|---|
| HMO/POS EPO, PPO (commercial plans) |
Authorization is not required for services from an in-network home health care provider.
If an HMO or EPO member is receiving care from an out-of-network provider, they will need an approved authorization for coverage because they do not have out-of-network benefits. |
| Medicare HMO Blue | Primary care providers (PCPs) or PCP-referred specialists with an open referral from the PCP may submit a global authorization for home health care services for up to 40 dates of service within 60 consecutive calendar days. These services must be entered as an authorization via electronic technologies.
No review is necessary for Medicare PPO Blue. |
| Federal Employee Program | No precertification is required for Federal Employee program members. For FEP-specific benefit information, call 1-800-451-8124. |
Tips for entering the global authorization (for Medicare HMO Blue members only)
- For Direct ANSI 278 connection, enter the Type of Service code 42.
- For Authorization Manager, follow the instructions in our Quick Tip and User Guide.
- For ConnectCenter, select “Home Health Care” from the Service Type drop-down menu.
Coverage criteria
To qualify for coverage, commercial members must meet InterQual® Home Care guidelines. We use Medicare guidelines to determine coverage for our Medicare Advantage members.
Cases in which the Medicare HMO Blue member requires more than 40 service days are often complex and may be referred to Case Management. Therefore, our Health Management department will review all requests for services beyond 60 dates of service. These services must be entered as an authorization.
If you cannot enter the global authorization because the member has already used the auto-approved home health care services within the time period specified, you will need to contact Health & Medical Management at 1-800-327-6716.
How to request additional services (for Medicare HMO Blue members only)
| If | The home health care provider should fax us these items for case management review | By this time |
|---|---|---|
| Additional home health care services are required beyond the initial auto-approval | A completed Home Health Authorization Extension Request Form and the:
|
At least seven calendar days before the visit limit has expired |
Our nurses will contact the member’s primary care provider, ordering specialist, or home health care agency to review the treatment plan and initiate the extension review process.
