HOME HEALTH CARE AUTHORIZATION REQUEST FORM 844-834-2908 PLEASE FAX THIS FORM ALONG WITH REQUIRED INFORMATION TO: 844-411-9622 Questions? Call Date of Request: Standard Request: Urgent Request: Note: Urgent request should only be submitted if waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. Retro Request: If member’s condition does not meet this description and the authorization is submitted as an Urgent Request, delays in processing may occur. Member Name: Referral Source: Required for Authorization Notification Phone: Fax: DOB: Member ID# (Required): Referral Source: Hospital SNF/Rehab MD Office HH Agency Date of D/C from facility or office visit: Preferred HH Provider: Has home health care already begun? Yes No Branch NPI (required): Phone: Start of Care Date/ Requested start of care date: Diagnosis: (incl. Codes) Ordering MD (required):________________________________________ HIPPS Code: Ordering MD NPI (required): ____________________________________ Phone: Fax: HOMEBOUND STATUS: Yes No: Able/willing/teachable caregiver? Yes No CMS Definition: Homebound status certified by MD; there is If no, please explain: a normal inability to leave home and leaving the home is a considerable and taxing effort. What is Being Reason for visits: Requested: Wound Care Skilled Nursing (include Foley or PEG care MD Home Healthcare signed order wound measurements, Access Care (port/PICC) name/dosage frequency of (Including signed verbal MD order) Teaching/Compliance medications if applicable) Other: PT (all therapy requests Supporting Clinical Documentation Evaluate and Treat should include current level of function and care At least one of the following is required: goals) History and Physical Communication ST Facility Discharge Summary Other Cognitive Progress Notes from Hospital or SNF Swallowing MD Office Notes Wound Care Pictures and Measurements To avoid potential MSW please include HHA the completed initial OT assessment and qualifying service Care Plan with all Dependent Service visits requests. Comments/ Notes:
HOME HEALTH CARE AUTHORIZATION REQUEST FORM PLEASE FAX THIS FORM ALONG WITH REQUIRED INFORMATION TO: 844-834-2908 Questions? Call 844-411-9622 Date of Request: Standard Request: Retro Request: Urgent Request: Note: Urgent request should only be submitted if waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. If member’s condition does not meet this description and the authorization is submitted as an Urgent Request, delays in processing may occur. Member Name: DOB: Referral Source: Required for Authorization Notification Phone: Fax: Member ID# (Required): Referral Source: Hospital SNF/Rehab MD Office HH Agency Date of D/C from facility or office visit: Preferred HH Provider: Branch NPI (required): Phone: Has home health care already begun? Yes No Start of Care Date/ Requested start of care date: Diagnosis: (incl. Codes) HIPPS Code: Ordering MD (required):________________________________________ Ordering MD NPI (required): ____________________________________ Phone: Fax: HOMEBOUND STATUS: Yes No: CMS Definition: Homebound status certified by MD; there is a normal inability to leave home and leaving the home is a considerable and taxing effort. Able/willing/teachable caregiver? Yes No If no, please explain: What is Being Requested: Reason for visits: MD Home Healthcare signed order (Including signed verbal MD order) Supporting Clinical Documentation At least one of the following is required: History and Physical Facility Discharge Summary Progress Notes from Hospital or SNF MD Office Notes Wound Care Pictures and Measurements Skilled Nursing (include wound measurements, name/dosage frequency of medications if applicable) Wound Care Foley or PEG care Access Care (port/PICC) Teaching/Compliance Other: PT (all therapy requests should include current level of function and care goals) Evaluate and Treat ST Communication Other Cognitive Swallowing MSW HHA OT To avoid potential please include the completed initial assessment and qualifying service Care Plan with all Dependent Service visits requests. Comments/ Notes:
Home-Health-Authorization-Request-Form-120517.docx