All home health visits for members require prior authorization. To request authorization use our Auth Request tool.
Medicare coverage education for providers
If you provide skilled home care services and/or skilled physical, occupational and speech therapy to Medicare beneficiaries, then you're required to understand the issues of the Jimmo v Sebelius case and the resulting Jimmo Settlement Agreement on coverage.
Learn more on our Jimmo Settlement Agreement page.
Standard contracted services
All contracts include home health care. The Jimmo v Sebelius Settlement clarified CMS rules for skilled care and related documentation. See our Jimmo v Sebelius page for details and requirements for home health education.
Retrospective authorizations
If you provide a service that requires prior authorization to an MA/MAPD plan member without first getting authorization, you can't send us an authorization request after the fact. You must submit a Request for payment. See Retrospective authorizations for details.
Appealing coverage for non-covered skilled care
Should the MA/MAPD plan member appeal the termination decision, Livanta, the Quality Improvement Organization (QIO) for the state of Michigan, notifies Priority Health of the member's appeal. Priority Health - not the home health care services - must then issue a CMS-10124 form, Detailed Explanation of Non-coverage (DENC).
No later than the close of business the day that it is notified of the member appeal, Priority Health must:
- Complete a CMS-10124 form, Detailed Explanation of Non-coverage (DENC), with specific and detailed information about why home health services are ending.
- Upload a copy of the form to the Michigan QIO, Livanta.
- Issue the DENC form to the plan member.
The DENC serves to inform the member of the reason for the coverage termination so he/she has an opportunity to present his/her views to the QIO.
Home health care agencies may not appeal on behalf of a member unless the home health care agency is member's appointed representative; proof may be required by the QIO.
Required appeal information for providers:
Be sure to have designated weekend and evening staff responsible for completing required tasks for Livanta.
Priority Health staff can assist you with questions for after-hours or weekend appeals. Call our on-call nurse at 800.259.1260.
The following information must be uploaded to Livanta:
- History and physical
- Physician orders
- Physician progress notes
- PT evaluation and progress notes
- OT evaluation and progress notes
- ST evaluation and progress notes
- Social service/DC planning notes
- Skilled nursing notes
- Wound care orders and flowsheets
- Face sheet
Livanta due dates and times:
- During regular business week/hours: 5:00 p.m. on same day
- After business hours: Noon the next day
- Weekends: 3:00 p.m. Monday
Find more information on Medicare in-home safety assessments and post acute care