Referral, Notification, and Authorization-Authorization

Harvard Pilgrim Health Care a Point32Health company

Home Health Care Authorization

Unless otherwise specified, information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport ConnectSM. For UnitedHealthcare’s related policies/procedures, please go to www.UnitedHealthcareOnline.com or call 800-708-4414.

Criteria

Harvard Pilgrim covers medically necessary VNA/Home Health services, including skilled nursing, physical and occupational therapy, home hospice care and home infusion therapy.

Home health aide services are covered only when those services are a medically necessary part of a skilled home health care plan. In most cases, the member must be home-bound for medical reasons (i.e., absences from the home must be infrequent, for relatively short duration and principally to access medical care). Home health services may also be authorized in situations where Harvard Pilgrim determines that the member’s residence is the most practical or clinically appropriate setting for the member to receive needed care or maximize independence. In all cases, there must be a defined medical goal that the PCP expects the member to meet, and services must be obtained from Medicare-certified, in-network providers.

Services that meet Harvard Pilgrim’s home health care criteria are automatically approved. Services that do not meet Harvard Pilgrim’s home health care criteria must be reviewed and authorized by a Harvard Pilgrim care manager or designee. Care managers are available during regular business hours (Mon.–Fri., 8:30 a.m.–5:00 p.m.). To identify the appropriate care manager, contact Member Services at 888-333-4742.

Action Required

Authorization requests should be initiated as early as possible (before initiation of services in most cases) to allow Harvard Pilgrim sufficient time to evaluate member eligibility, level of benefits and medical necessity. If services are initiated outside of regular business hours, the provider must request authorization by the next business day.

Authorization for home health services may be requested electronically via HPHConnect or NEHEN, or by faxing a completed Universal Home Care form to 617-509-1147.

If electronic submission is not possible, contact a nurse care manager to request authorization.

To identify the appropriate nurse care manager, contact Member Services at 888-333-4742.

Request prior authorization through one of the following channels:

• Electronic Submit a transaction record with required information using the HPHConnect or NEHEN transaction service.

• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at HPHConnect/User Guides. )
• For NEHEN instructions, refer to your NEHEN documentation.

Harvard Pilgrim Response

The request pends for receipt of medical information and nurse reviewer evaluation. Evaluation is completed within two business days after receipt of medical information. The final status will be available online.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.9

January 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Information Required

The following information is required for a home health care request.

• Member’s name and Harvard Pilgrim identification number
• Vendor’s name and National Provider Identifier (NPI)
• Diagnosis and clinical information
• Ordering physician’s National Provider Identifier (NPI)
• Location
• Service(s) requested

All requests for services must be submitted with a valid NPI for the requesting and servicing providers.

Medical Information

To facilitate the transaction process, submit medical information to the designated Harvard Pilgrim nurse care manager as soon as possible.

To identify the designated nurse care manager, contact Member Services at 888-333-4742.

Authorization Changes

Harvard Pilgrim must be informed when any change to an authorized admission occurs, such as a revision to the services or a renewal of the services.

Electronic

Electronic Edit the existing transaction record or submit a new transaction record through the HPHConnect or NEHEN transaction service.

• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.

Telephone

Telephone Fax changes to the designated Harvard Pilgrim nurse care manager. Contact the nurse care manager for the fax number.

Acute Hospital Admissions for Hospice Patients

Application of Standard Medical Benefits

The member’s standard medical benefits apply in the following situations:

• If inpatient care is necessary to treat a condition not related to the terminal illness (e.g., hip fracture caused by a fall).
• When inpatient care is required for aggressive treatment of the terminal illness; access to the home hospice benefit is terminated but may be reactivated upon discharge (after reassessment by the home hospice provider).

Application of Hospice Benefits

Inpatient care covered under the hospice benefit must be related to the terminal disease (e.g., acute exacerbation, pain management and/or management of clinical symptoms that cannot be safely managed in the home care setting). The hospice benefit includes coverage for limited respite care (i.e., up to five days every three months, to a maximum of 14 days per calendar year).

PUBLICATION HISTORY

• 03/15/11 minor edits for clarity
• 01/01/12 removed First Seniority Freedom information from header
• 10/02/19 administrative edit

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.10

January 2023