Home health review prior authorization updates

Starting May 1, 2023, we'll require prior authorization for home health services for UnitedHealthcare Dual Special Needs Plan (D-SNP) members receiving home health services in the following states: 

For all visits after the start of care (SOC) visit, you’ll need to request prior authorization through naviHealth.

Note: We already require prior authorization from naviHealth for UnitedHealthcare® Medicare Advantage plan members who receive home health services in the states mentioned above.

Excluded plans

Plans and groups not affected by this requirement include:

• UnitedHealthcare commercial plan
• UnitedHealthcare Community Plan
• 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

What you need to know

• UnitedHealthcare has delegated the prior authorization and concurrent review processes for home health services to naviHealth. We’ll use the criteria in our Advance Notification and Plan Requirement Resources to facilitate our home health authorizations and concurrent reviews. You can request authorization using the naviHealth online portal, nH Access. You will receive an electronic notification of your request status through the portal.
• You do not need to request prior authorization for home health services furnished as part of a plan of care initiated prior to May 1. This includes home health cases still open on May 1. All existing home health services as of May 1 may continue and do not require naviHealth’s review or prior authorization until you need a recertification or resumption of care.  
• Start of care visits do not require prior authorization. You can perform a comprehensive evaluation of your patient in their home setting without prior authorization from naviHealth.
• After the start of care visit, request prior authorization through naviHealth for:
  • Continuation of care requests
  • Resumption of care requests
  • Recertifications

Questions?

If you have questions about the prior authorization submission process, email info@navihealth.com.

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