Managed Care Operations Memorandum General …

1 Managed care Operations Memorandum General Operations MCOPS Memo # 07/2016-008 DATE: July, 22, 2016 SUBJECT: Guidance Regarding the Review of Requests for Skilled Nursing, Personal care Services, Including that Provided by Home Health Aides TO: All HealthChoices PH-MCOs care Organizations Statewide FROM: Laurie Rock, Director, Bureau of Managed care Operations Purpose: To provide guidance to the Physical Health Managed care Organizations (PH-MCOs) regarding prior authorization policies and the review of requests for skilled nursing and personal care services, including services provided by home health aides, for members under the age of twenty-one (21).

2 Background: MC Ops Memo #MCS-07/2010-014, Policies Concerning Medical Necessity Determinations for In-Home and Community services, was issued on July 10, 2010. The intent of this MC Ops Memo was to remind all HealthChoices PH-MCOs of the policies governing medical necessity determinations for in-home and community services. Over the last several years, the Department of Human Services (the Department) has continued to review prior authorization policies submitted to the Department s Prior Authorization Review Panel (PARP) for approval for skilled nursing and personal care services, denial notices issued to beneficiaries, and complaints regarding denials of these services.

3 Based on this experience, the Department has determined additional guidance to PH-MCOs is necessary, including expectations, regarding the coverage of these services. Discussion: As outlined in the HealthChoices Agreement, the PH-MCO is responsible to provide all medically necessary covered services for eligible recipients under 21 years of age. The PH-MCO may require prior authorization for skilled nursing and personal care services, including those provided by home health aides. However, if prior authorization is required, the PH-MCO must receive advance written approval from the Department for the prior authorization policy.

4 In addition, PH-MCOs must conduct reviews to determine the medical necessity for these services for members under the age of twenty-one (21). All PH-MCO policies and processes for reviews of requests for these services must adhere to the following: 1. Each request for service must be reviewed for medical necessity using the definition of medical necessity set forth in the HealthChoices Agreement. The definition must be contained within the PH-MCO prior authorization policy. 2. Consistent with federal guidance, it is and has been the policy of the Department that medically necessary skilled nursing services and personal care services, including those provided by home health aides, may be provided to a child in the home and in settings outside of the child s home.

5 3. PH-MCOs cannot require a minimum number of specified hours [ , four (4) continuous hours] be medically necessary in order to authorize services. Each request submitted must be reviewed for medical necessity on its own merit and an appropriate decision rendered. 4. The PH-MCO must have sufficient information to determine medical necessity. If sufficient information is not received, the PH-MCO must make every effort to obtain the needed information before denying a request based on lack of information.

6 The PH-MCOs must consider the following prior to rendering a denial for lack of information. a. Did the requesting provider submit a complete Letter of Medical Necessity (LOMN) and/or a plan of care /treatment plan that identifies the course of treatment, the member s diagnosis, level of care or other information necessary to render a decision? If the information is not submitted with the request, the PH-MCO must outreach to the ordering provider to request the outstanding information by a given date prior to sending a Request for Additional Information Letter , Exhibit N(7), of the HealthChoices Agreement.

7 B. Did the PH-MCO case manager outreach to the child s family, requesting physician and the provider if applicable to collect additional needed information about the situation such as caregiver work schedules, other responsibilities of caregivers in the home, 5. When requests are denied as not medically necessity, the denial notice must include an explanation that identifies the specific reasons why the service requested was determined to be not medically necessary. 6. A request may not be denied based on the following: c.

8 Because a parent or caregiver is present in the home unless the PH-MCO has adequate documentation that substantiates the parent or caregiver is actually able and available to provide the child s care during the time hours are requested. d. Because the service will be provided in a location outside of the child s home, such as, but not limited to, a school setting. e. Because the PH-MCO believes that the service should be covered as part of a child s Individualized Education Program (IEP) or Section 504 Plan (Section 504 of the Rehabilitation Act of 1973 [29 794]).

9 Next Steps: 1. The PH-MCOs must revise their Prior Authorization policies relating to skilled nursing services, personal care services, including those provided by home health aides, based upon information in this MC Ops Memorandum and submit the revised policy through the Prior Authorization Review Panel (PARP) for review and approval no later than 60 days after the issuance date of this MC Operations Memorandum . 2. The Department will continue to monitor denials, complaints, grievances and application of approved prior authorization policies for these services.

10 3. PH-MCOs should submit any questions regarding this MC Operations Memorandum to their assigned BMCO Contract Manager. Obsolete: This MC Operations Memorandum will be in effect until further notice. In addition, MC Operations Memorandum #MCS-07/2010-014 also remains in effect until further notice.