Home Care Services

New Start of Care & Evaluations:

• Referral from physician/facility, or discharge summary from facility

*Only applies to one (1) visit for nursing, physical therapy, and/or occupational therapy

Continuation of Care after Evaluation:

• Current completed OASIS with documentation of verbal orders received for all requested visits; and/or
• Current CMS-485 Home Health Certification and Plan of Care signed by agency clinician that received verbal orders for the plan of care and/or signed by the Physician; and
• Supporting documentation of the member’s need for skilled home health services, such as evaluations/assessments and progress notes for each requested discipline

Recertification of Existing Services:

• Applicable CMS-485 Home Health Certification and Plan of Care signed by agency clinician that received verbal orders for the plan of care and/or signed by the Physician; and
• Recertification assessment/evaluation for each requested discipline that addresses progress towards meeting goals with objective measurements, response/barriers to education/managing care, and adherence issues.

INTEGRITY (MMP): Clinical documentation is not required but the requested hours and services must match the hours and services the member’s care manager approved as medically necessary.

Medicaid (RHE, RHP, MED, CSN, SUB):
**If transferring hours between agencies, then a Release of Hours Letter is preferred from the agency releasing the hours advising the number of hours released to the new agency, the start date of the transfer, and the end date of the transfer (if applicable)

New Start of Care or Increased Services:

• Documentation that the services are part of a physician’s plan of care, such as doctor’s orders, letter of medical necessity, referral, etc., AND
• If not completing the ADL grid below, then provide documentation indicating the level of assistance the member needs with each Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), such as a completed Minimum Data Set (MDS) for Home Care or a completed Provider Medical Statement (PM1) from the member’s physician within the last year. AND
• Current aide plan of care

Continuation of Services:

• If not completing the ADL grid below, see the second bullet point in the New Start of Care or Increased Services section above. AND
• Current aide plan of care

**If transferring hours between agencies, then a Release of Hours Letter is needed from the agency releasing the hours that includes: the number of hours released to the new agency, the start date of the transfer, and the end date of the transfer (if applicable)

New Start of Care and Continuation of Care:

• Current, comprehensive Plan of Care (POC) signed by agency clinician that received verbal orders for the plan of care and/or signed by the Physician. All PDN requests require ongoing supervision by the treating physician.
• Up to two (2) weeks of the most recent nursing notes detailing all nursing interventions and care provided during the nurses’ shift.
• If applicable, provide a complete description of any wounds: size, depth, drainage, type, and wound care orders.
• If a member has a change in condition or caregiver status that requires additional PDN coverage, you can submit a request to increase hours at any time with supporting documentation to be reviewed.