Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111

MassHealth
Home Health Agency Bulletin 35
May 1999

TO:      Home Health Agencies Participating in MassHealth

FROM:      Bruce M. Bullen, Commissioner

RE:      CHANGES IN THE PRIOR AUTHORIZATION PROCESS FOR PRIVATE-DUTY NURSING SERVICES

Background                       This bulletin informs home health agencies of changes to the
prior-authorization process for private-duty nursing services effective
May 1, 1999.  To incorporate these changes into the total
prior-authorization process, this bulletin also reviews certain policy and procedures that are not changing.

Important Changes            Effective May 1, 1999, the Division will change the following procedures for obtaining prior-authorization (PA) for private-duty nursing services.

·     The Division will determine the duration of the prior-authorization period on a case-by-case basis, rather than granting a standard three-month period, according to the medical needs of the MassHealth member, using the clinical documentation that you have submitted.

·     For changes during the PA period, the Division has developed an adjustment form to:
·  report unused authorized hours; and
·  follow up a telephone request for an increase or decrease of
   hours.

·     You must notify the Division by telephone when a member has been admitted to and/or discharged from a hospital during a prior- authorization period.

MassHealth
Home Health Agency Bulletin 35
May 1999
Page 2

Initial Prior                        The home-health agency must continue to use the Division’s process to Authorization                     obtain initial prior authorization of private-duty nursing services.  To Procedure                         obtain initial prior authorization a nurse from the home-health agency
must:

·     perform a medical-necessity screening of the MassHealth member before telephoning the Division to request prior authorization; and

·     submit a completed Request for Prior Authorization form and a Request and Justification for Continuous Skilled-Nursing Services form to the Division within two weeks of verbal authorization.

Reauthorization                 For reauthorization of private-duty nursing services, a nurse from the
Procedure                         home-health agency must submit an updated Request for Prior Authorization form and a Request and Justification for Continuous Skilled-Nursing Services form to the Division at least two weeks before the expiration date of the current prior-authorization period.

Duration of                        The Division has changed its policy for the maximum duration of a prior Prior Authorization            authorization.  The three-month limit no longer applies.  The Division will determine the duration of an initial prior authorization or a reauthorization
based on the clinical criteria in the Private Duty Nursing Manual at 130
CMR 414.400 and the medical necessity regulations at 130 CMR
450.204.

New Adjustment                Effective May 1, 1999, providers must submit to the Division a completed
Form                                 adjustment form to report unused authorized hours or to follow up on a telephone request for an increase or decrease in the number of authorized hours. A nurse from the home-health agency must complete, sign, and date the form.

Adjustment for Unused Hours

If you do not use the authorized number of hours, you must submit an adjustment form to the Division with a detailed reason for the unused hours (examples:  shortage of nursing staff or the member entered a respite-care facility, nursing facility, or hospital).  Where shortage of nursing staff is the reason for unused hours, you must document attempts to co-vend with other MassHealth-approved home-health agencies.

You must submit the completed adjustment form monthly during the prior-authorization period whenever unused hours occur.  Include specific dates, hours, procedure codes, and your reason for the unused hours.

MassHealth
Home Health Agency Bulletin 35
May 1999
Page 3

NEW Adjustment               Adjustment for Changes in Authorized Hours
Form (cont.)
If it is medically necessary for the MassHealth member to receive more hours of private-duty nursing than the authorized amount, you must telephone the Division to request additional hours.  If a member’s medical condition requires a decrease in the authorized amount, you must telephone the Division to request a decrease. You must submit the completed adjustment form with the requested increase or decrease in hours within two weeks of your call to the Division.  Include specific dates, hours, procedure codes, and your reason for the increase or decrease.

Member                             When a member has been admitted to or discharged from a hospital
Hospitalization                   during a prior-authorization period, you must notify the Division by telephone.

Address for PAs                Mail your completed prior-authorization requests and completed
And Adjustments               adjustment forms to the following address. Division of Medical Assistance Prior Authorization Unit
600 Washington Street
Boston, MA  02111

Supplies                            To obtain supplies of the Division’s adjustment form, send or fax a written request to the following address or fax number.

Unisys
ATTN: Forms Distribution
P.O. Box 9101
Somerville, MA  02145
Fax:  (617) 576-4087

Telephone Numbers           To request a prior-authorization clinical intake, an adjustment to a current prior authorization, or to notify the Division of a hospital admission or discharge within a prior-authorization period, call (617) 210-5714.

To inquire about the Division’s receipt of a prior-authorization form, call
(617) 210-5582.

For questions about this bulletin, call the Unisys Provider Services
Department at (617) 628-4141 or 1-800-325-5231.

MassHealth
Home Health Agency Bulletin 35
May 1999
Page 4