New home health prior authorization review process
Affected states include California, Iowa, Kansas, Massachusetts, Pennsylvania and Wyoming
Starting Aug. 1, 2023, for UnitedHealthcare® Medicare Advantage and Dual Special Needs Plans (D-SNP), you’ll need to request prior authorization for all visits after the start of care (SOC) visit through naviHealth.
The visits included in the prior authorization will be:
- Continuation of care
- Resumption of care (ROC)
- Additional services
- Recertification
SOC visits do not require prior authorization.
Impacted plans
This new process will apply to members enrolled in Medicare Advantage plans, including D-SNP members, who receive services in California, Iowa, Kansas, Massachusetts, Pennsylvania and Wyoming.
Plans and groups not affected by this requirement include:
- UnitedHealthcare commercial
- UnitedHealthcare Community Plan (Medicaid)
- Institutional Special Needs Plans (I-SNP), Institutional Equivalent Special Needs plans (I-ESNPs)
- Long-Term Support Services Fully Integrated Dual-Eligible Plans (i.e., FIDE, HIDE and MMP)
- Any delegated provider medical groups
For states and UnitedHealthcare Medicare Advantage and D-SNP not mentioned, current existing requirements and processes remain unchanged.
What you need to know
We will delegate the initial authorization and concurrent review processes for home health services to naviHealth. We’ll use the criteria in our Medicare Advantage Prior Authorization Requirements to facilitate our home health authorizations and concurrent reviews.
You can request authorization using nH Access — the naviHealth online portal. You will receive an electronic notification of your request status through the portal.
You don’t need to request prior authorization for home health services furnished as part of a plan of care initiated prior to Aug. 1. This includes home health cases still open on Aug. 1. All existing home health services as of Aug. 1 may continue and don’t require naviHealth’s review or prior authorization until you need a recertification or resumption of care.
Questions?
If you have questions about the prior authorization submission process, email info@navihealth.com.
