|Highmark Commercial Medical Policy - Pennsylvania|
|Topic:||Physician Certification and Recertification of Home Health Services|
|Effective Date:||January 1, 2012|
|Issue Date:||May 14, 2018|
|Last Reviewed:||May 2018|
This policy provides guidelines for certification and recertification by physicians for home health services.
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.
|Policy Position Coverage is subject to the specific terms of the member’s benefit plan.|
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.
Recertifications must be signed by the physician who reviews the plan of treatment. The form of the recertification and the manner of obtaining timely recertifications are up to the individual home health agency.
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.
|Place of Service: Outpatient|
|The policy position applies to all commercial lines of business|
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
10/2011, Certified registered nurse practitioners now eligible to document face-to-face patient encounters for certifying home health services
06/2012, Face-to-face encounter requirements clarified
05/02/2012, Clarification: Face-to-face encounter requirement does not apply to three specific home health situations