|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Coverage for home health services is determined according to individual or group customer benefit.
Payment can be made for covered home health services that a home health agency provides if a physician certifies that:
As a condition for payment, prior to certifying a patient’s eligibility for the home health benefit the certifying physician must document that he or she, or an allowed professional provider has had a face-to-face encounter with the patient. The initial certification is incomplete without them.
The certifying physician must document that he or she or an allowed professional provider had a face-to-face encounter with the patient. In addition to the physician, a certified registered nurse practitioner, who is the member’s primary care provider, can document the face-to-face patient encounter and sign the certification.
Other professional providers may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. In addition to the physician, professional providers who are allowed to perform the face-to-face encounter are:
Face-to face encounters should be reported with the most appropriate evaluation and management service that accurately reflects the level of care provided.
The face-to-face encounter requirement described above does not apply to the following:
Encounter Documentation Requirements
The documentation must include the date when the physician or allowed professional provider saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
When a home health patient dies shortly after the start of care, before the face-to-face encounter occurs, if it has been determined that a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.
If the below conditions are met, an encounter between the home health patient and the attending physician who cared for the patient during an acute/post acute stay can satisfy the face-to-face encounter requirement.
Recertifications for Home Health Services
When services are continued for a period of time, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of the plan.
The physician must recertify that the individual continues to meet the guidelines for home health services as indicated above.
NOTE: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illnessndition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illnessndition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
06/2011, Physician certification and recertification of home health services: new coverage guidelines explained
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.