| (C) If the face-to-face encounter is performed by a
nurse practitioner, clinical nurse specialist, or physician assistant,
the practitioner must communicate the clinical findings of that encounter
to the ordering physician, and the physician ordering the services
must:
(i) record the date of the face-to-face encounter and
the practitioner who conducted the encounter;
(ii) affirm that the face-to-face encounter is related
to the primary reason the patient requires home health services and
that the encounter occurred within 30 days prior to the start of home
health services; and
(iii) include the clinical findings of the encounter
in the patient’s medical record.
(2) Time limited prior authorizations.
(A) Prior authorizations for payment of home health
services may be issued by HHSC for a service period not to exceed
60 days on any given authorization. Specific authorizations may be
limited to a time period less than the established maximum. When the
need for home health services exceeds 60 days, or when there is a
change in the service plan, the provider must obtain prior approval
and retain the physician's signed and dated orders with the revised
plan of care.
(B) The provider shall be notified by HHSC in writing
of the authorization (or denial) of requested services.
(C) Prior authorization requests for covered Medicaid
home health services must include the following information:
(i) The Medicaid identification form with the following
information:
(I) full name, age, and address;
(II) Medical Assistance Program Identification number;
(III) health insurance claim number (where applicable);
and
(IV) Medicare number;
(ii) the physician's written, signed, and dated plan
of care (submitted by the provider if requested);
(iii) the clinical record data (completed and submitted
by provider if requested);
(iv) a description of the home or living environment;
(v) a composition of the family/caregiver;
(vi) observations pertinent to the overall plan of
care in the home; and
(vii) the type of service the patient is receiving
from other community or state agencies.
(D) If inadequate or incomplete information is provided,
the provider will be requested to furnish additional documentation
as required to make a decision on the request.
(3) Medication administration. Nursing visits for the
purpose of administering medications are not covered if:
(A) the medication is not considered medically necessary
to the treatment of the individual's illness;
(B) the administration of medication exceeds the therapeutic
frequency or duration by accepted standards of medical practice;
(C) there is not a medical reason prohibiting the administration
of the medication by mouth; or
(D) the patient, a primary caregiver, a family member,
and/or a neighbor has been taught or can be taught to administer intramuscular
(IM) and intravenous (IV) injections.
(4) Prior approval. Services or supplies furnished
without prior approval, unless otherwise specified by HHSC, are not
benefits.
(5) Recipient residence. Services, equipment, or supplies
furnished to a recipient who is a resident or patient in a hospital,
skilled nursing facility, or intermediate care facility are not benefits.
(c) Home health services are subject to utilization
review, which includes the following:
(1) the physician is responsible for retaining in the
client's record a copy of the plan of care and/or a copy of the request
form documenting the medical necessity of the health care service,
supply, equipment, or appliance and how it meets the recipient's health
care needs;
(2) the home health services provider is responsible
for documenting the amount, duration, and scope of services in the
recipient's plan of care, the equipment/supply order request, and
the client record based on the physician's orders. This information
is subject to retrospective review; and
(3) HHSC may establish random and targeted utilization
review processes to ensure the appropriate utilization of home health
benefits and to monitor the cost effectiveness of home health services.
|
| Source Note: The provisions of this §354.1039 adopted to be effective June 26, 1997, 22 TexReg 5826; amended to be effective July 1, 1999, 24 TexReg 4365; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 14, 2002, 27 TexReg 10588; amended to be effective October 2, 2016, 41 TexReg 7475 |
