Back to Insights and Updates for ProvidersApril 2024

Utilization management update for home health care services

Harvard Pilgrim Health Care Commercial  |  Tufts Health Plan Commercial

Point32Health is updating our utilization management requirements for home health care services, effective for dates of service beginning April 12, 2024, with the aim of maximizing the quality and efficiency of the care our members receive while minimizing the administrative burden on our providers.

Notification for initial 30 days of service

Currently, skilled services provided in the home (e.g., physical therapy, occupational therapy, and speech-language pathology services; social work visits; home health aides; skilled nursing; nutritional counseling) require prior authorization after the initial evaluation for Harvard Pilgrim and Tufts Health Plan Commercial plans. As of April 12, these services will instead require notification for the first 30 days of service — after the initial 30 days, prior authorization will be required for continuation of coverage.

We anticipate that this change will improve turnaround times and better facilitate the coordination of care, getting members out of the hospital and back home sooner so they can begin their at-home treatment protocols.

We’ve updated our Medical Necessity Guidelines (MNG) for Home Health Care Services to reflect this change.

Please keep in mind that while prior authorization and notification requirements for home health care services are changing as identified above, the methods of submitting a prior authorization or notification request are not; continue to submit those requests as you do today.

For guidance on submitting notifications and prior authorization requests, please refer to the Referral, Notification and Authorization Policy in the Harvard Pilgrim Health Care Commercial Provider Manual and the Referrals, Prior Authorizations and Notifications section of the Tufts Health Plan Provider Manual.

Proper claim submission reminder

As a reminder, consistent with proper billing practices, when submitting a notification or prior authorization request for home health care services, please report all requested services on one claim, rather than submitting multiple claims.

Audrey Kleinberg,
Director, Provider Relations & Communications

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Senior Manager, Provider Communications

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