2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Home Healthwill authorize continued care only if theprovider agrees to all of the following:• Accept reimbursement from Presbyterianat the rates applicable before the start ofthe transitional period• Adhere to PHHSN’s quality assurancerequirements and provide PHHSN withnecessary medical information related tosuch care• Adhere to PHHSN’s policies andprocedures, including but not limited toprocedures regarding referrals, priorauthorization, treatment approved byPHHSN, cultural competency, andconfidentialityDenialsAll referrals and requests for home health careservices that do not meet treatment requirementsor medical necessity criteria, as determined byPHHSN quality review nurses, will be referred tothe Presbyterian medical director to review for adecision regarding appropriateness of care througha home health care agency. Additionally, allreferrals and requests for services, includingrequests for new technologies, will be reviewed bythe PHHSN quality review nurse.There are several situations that would result in apatient being denied for care by PHHSN. Thefollowing are examples of these situations identifiedthrough an initial screen:Some patients will not be eligible for carebecause our network is not the designatedcontractor for the patient’s payer sources. Theagency may inform the patient that they maychoose to go “out of plan” and pay for servicesprivately; the PHHSN does not need toapprove these casesThe care request is for a service not providedby the networkAdditional situations in which PHHSN quality reviewnurses may perform administrative denials areFailure of a provider or practitioner to providemedical or other individualized informationneeded to establish medical necessityFailure to comply with contract requirementsin non-urgent/non-emergent situationsAll requests that lack physician ordersAll late requests that do not fall within theallowable retroactive authorization policyThe quality review nurse will clearly document thereason for each denial on the Prior AuthorizationRequest Form. When any of the above situationsoccur, the referral source will be notified byPHHSN, as appropriate. Documentation is kept onfile.If a patient refuses services, the agency isresponsible for contacting the physician, who maydiscuss with the patient the rationale for home careservices. If the patient subsequently agrees, thepatient may need to reenter the system throughPHHSN.If the PHHSN quality review nurse questions themedical necessity of the request for authorization,discussion between the PHHSN quality reviewnurse and the agency or referral source will beinitiated. If consensus cannot be reached, a request11-72014 Practitioner and Provider Manual - Ver. 3