2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Home Healththese services. Services may be approved for sixmonthtime periods.Retroactive AuthorizationsRetroactive authorizations are not provided as ageneral rule. However, for those medicallynecessary home care visits ordered by a physicianduring normal business hours for a same-day visitor a new referral requiring a same-day visit, a priorauthorization will be provided if the request isreceived on the next business day.Also, in those cases when medically necessary butunscheduled visits are ordered by the physicianafter business hours or on a weekend or holiday, aprior authorization will be issued when requestedby the end of the next business day. Agenciesshould normally request prior authorization forhome health care services before providing theservices.Co-payments, Co-insurance, and DeductiblesThe agency will be informed by PHHSN of anyPresbyterian commercial plan member’s copayments,co-insurance, or deductible or applicableco-payments under Medicaid State Children’sHealth Insurance Program or Working DisabledInsurance. The agency is responsible for informingthe patient of his or her financial responsibilitybefore initiation of home care services. The agencyis responsible for billing the member and collectingall co-payments and deductibles as they relate tohome care services. Co-payments are based uponan agency’s Presbyterian contracted rates, notupon an agency’s charges.Transition of CarePHHSN allows for the transition of Presbyterian ,members who are in need of home care services.This transition may involve members who arechanging from another insurer to PHP for memberswhose home care provider leaves the PHHSNnetwork of agencies. PHHSN will facilitatecontinuity of home care services while memberstransition to or from PHP or if the member changeshome care providers within the plan. Members willbe offered the following transition of care benefits:If the member’s home health care providerleaves the statewide network of home careproviders, PHHSN will permit the member tocontinue an ongoing course of treatment withthe original home care provider for atransitional period.The transitional period will continue for a timethat is sufficient to permit coordinatedtransition planning consistent with themember’s condition and needs relating to thecontinuity of the care. The transition periodmay be extended for a period of up to 90days.PHHSN will not be required to permit themember to continue treatment with a currenthome care provider if the provider is no longeraffiliated with PHHSN because of reasonsrelated to professional behavior or providercompetence.PHHSN will authorize continued care asrequired by applicable law or regulation,currently not less than 30 days. If thetransitional period exceeds 30 days, PHHSN11-62014 Practitioner and Provider Manual - Ver. 3