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We recently announced that we have eliminated authorization requirements for home health care services for our commercial members. This is intended to ease administrative burden and provide quick access to our members who need home care services—especially those being discharged from an inpatient facility who want to continue treatment at home.
Here we answer questions we’ve received from home health care agencies about this announcement and share information about our home health care benefit as it relates to mental health services.
For dates of service on and after January 1, 2024:
1 Federal Employee Program members already do not require authorization.
We continue to require authorization for:
We don’t require referrals for home health care services. Orders can be written by the member's treating provider—PCP, psychiatrist, or other specialty.
Use an online tool, such as ConnectCenter, to check member benefits and eligibility.
If you’d like to see if the member has a benefit maximum for home health care services, see our ConnectCenter Quick Start Guide (screenshot below) for instructions.
For commercial members, we use InterQual®' criteria to determine medical necessity. To access the InterQual criteria, you’ll need to log on to Provider Central and navigate to Clinical Resources>InterQual Criteria. Click the “Go now” button and select “LOC: Home Care Q & A” to access them.
For commercial members, we use InterQual®' criteria to determine medical necessity.
For Medicare Advantage members, we use CMS’ criteria.
Keep in mind that members with mental health conditions may qualify for home health care services, just as members with physical conditions do. For example, patients may be eligible for home health services if they are recently discharged from an inpatient stay at an acute care hospital or a behavioral health hospital and need medication administration support for injectable medications.
Here's how this might work:
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