Pennsylvania - new requirements for skilled shift care services

Last modified: February 1,  2021

Effective Jan. 1, 2021, we’re implementing new documentation requirements for providers making initial prior authorization requests for skilled shift care services, in accordance with Milliman Care Guidelines, 23rd edition.

At a later date that is yet to be determined, the documentation requirements will also apply for renewal requests and requests for transition of services.

This change applies to skilled shift care requests made for UnitedHealthcare Community Plan members in Pennsylvania ages 21 and younger. The documentation requirements are as follows:

Initial requests for authorization
When making an initial request for shift care services, please include all of the following:

  • Comprehensive assessment of the member’s health status including, but not limited to, documentation of the skilled care need and orders for medication
  • Discharge summary or recent progress note if the member is being discharged from an inpatient setting (Note: If the member is requesting shift care services for discharge from an inpatient setting, subspecialist visit notes are not required)
  • Consultation notes if the member is receiving services from a subspecialist
  • An assessment of the scope and duration of shift care services being requested
  • An assessment of the available support system, which must include, but is not limited to, all of the following:
    • Availability of the member’s primary caregiver
    • Ability of the member’s primary caregiver to provide care
    • School attendance and availability of coverage for services by school district, if applicable
    • Primary caregiver’s work schedules and travel time, as applicable, will be requested by UnitedHealthcare Community Plan. To assist in information gathering, we will fax a checklist with all of the above to the requesting provider office

Note: Additional documentation clarifying clinical status (such as well-child visits and/or specialist visit notes) may be requested if the clinical documentation provided does not clearly support the hours being requested.

Upcoming requirements for renewal or transition of services
At a later date, the following will be required when requesting a renewal or transition of services.

Renewal of services
Requests for renewal of shift care services will require all of the following specific clinical documentation to support medical necessity:

  • Home Health Certification and Plan of Care (CMS-485) form signed by a physician (MD or DO)
  • Nurses’ notes, logs and daily care flow sheets
  • Verification of primary caregiver’s employment schedule annually, as applicable

Transition of services
If a member is transitioning from another health plan and is already receiving shift care services, all of the following documentation must be submitted before the end of the required continuity of care period:

  • Home Health Certification and Plan of Care (CMS-485) signed by a physician (MD or DO)
  • Nurses’ notes, logs and daily care flow sheets
  • Verification of the primary caregiver’s employment schedule annually, as applicable

If you need help requesting transition of services, please contact one of our UnitedHealthcare Community Plan utilization nurses:

Existing requirements for skilled shift care
In addition to the new documentation requirements outlined above, these existing requirements are still in effect for 2021:

  • Letter of medical necessity from the members physician to confirm:
    • The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability
    • The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability
    • The service or benefit will help the member achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for members of the same age
  • Requirements for coverage:
    In order for the member to be covered for skilled shift care, all of the following must apply. The member:
    • Needs skilled care that exceeds the scope of intermittent care
    • Needs services that require the professional proficiency and skills of a licensed nurse (RN  or LPN)
    •  Is unable to have their care tasks provided through intermittent care or self-directed care
    • Has a complex medical need and/or unstable medical condition that requires 4 or more continuous hours of skilled care, which can be safely provided outside an institution
    • Requires skilled care that is medically necessary for the member’s disease, illness or injury, as defined by the member’s physician and consistent with the Pennsylvania definition of medical necessity
    • Has family or other appropriate support that has the ability and availability to be trained to care for the member and assume a portion of the care (Note: The intent of shift care services is to support, not replace, the caregiver)
    • Periodically reviewed treatment plan (no more frequently than every 60 days) updated by the treating physician

Coverage limitations and exclusions
The following coverage limitations and exclusions apply:

  • Medical and nursing documentation shows that the member’s condition is stable/predictable/controlled and that a licensed nurse is not required to monitor the condition
  • The plan of care does not require hands-on nursing interventions (Note: Observation in case an intervention is required is not considered skilled care)

The following are examples of services that do not require the skill of a licensed nurse and therefore, do not meet the medical necessity requirements for shift care services:

  • Any duplication of care that is already provided by supply or infusion companies
  • Help with daily living activities, such as but not limited to, walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods, and assistance with periodic turning and positioning in bed
  • Watching or protecting a member