New home health prior authorization review process
Starting Feb. 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.
The visit types included in the prior authorization requirement are as follows:
- Continuation of care
- Resumption of care (ROC)
- Additional services
- Recertification
Note: 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 Maine, Nebraska, Oklahoma, Rhode Island, Tennessee, Utah and Wisconsin. We’ll perform continuation of care reviews for Home Health Agencies (HHAs).
Plans and groups out of scope for this new requirement include:
- UnitedHealthcare commercial plans
- 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
- Any delegated provider medical groups
For all other states and plans, existing requirements and processes remain unchanged.
What you need to know
UnitedHealthcare 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.
Requesting authorization
You can request authorization using the naviHealth nH Access – naviHealth online portal. You’ll receive an electronic notification of your request status via the portal. Portal requests are the preferred method for authorization requests, but if needed, naviHealth can accept requests by fax to 888-815-1808.
Note: Members with delegated PCPs should follow the current process for authorizations. We are not making any changes to that process.
Questions?
If you have questions about the prior authorization submission process, email info@navihealth.com.
