Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Referrals and Prior
Authorization
11-6
Statement of Need for PCA Services
In accordance with Minnesota Statute 256B.0655, a physician’s
statement of need must be obtained before the start of services and
annually thereafter. The statement of need must include the
member’s diagnosis and condition for which the PCA services are
needed. The statement of need must also be utilized any time there
is a change in the member’s condition that results in a change in
the level of PCA services.
The Minnesota Council of Health Plans has collaborated with all
health plans to develop a universal statement of need form for the
PCA program. This statement of need form is posted on the MN
Council of Health Plans website at www.mnhealthplans.org.
Blue Cross requires that the form be completed prior to the start of
any PCA services. Services must be provided by a par provider.
Process for Initiating PCA Services
1. Prior to rendering PCA services to a Blue Plus Public
Programs member, providers should contact the member’s case
manager, care coordinator or IHM Utilization review area as
follows:
For Blue Advantage PMAP members, contact the
Government Programs Integrated Health Management
Intake at (651) 662-5540 or 1-800-711-9668.
For SecureBlue and MSC+ members, contact the member’s
county coordinator, if known, to request PCA services. For
assistance in locating the member’s county care
coordinator, contact Government Programs Integrated
Health Management Intake at (651) 662-5540 or at
1-800-711-9868. SecureBlue members are those members
with Minnesota Senior Health Options (MSHO) coverage
through Blue Plus.
2. An assessment of the member’s need for PCA services will be
completed by a public health nurse, Elderly Waiver case
manager or county care coordinator that has been trained by
the Department of Human Services.
3. Once completed, the PCA assessment should be faxed to
Government Programs Integrated Health Management at
(651) 662-4022 or 1-866-800-1665 for review.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)