MassHealth Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Standard Documentation to Include with a Prior Authorization Request for Personal Care Attendant (PCA) Services The following is a list of documentation that Personal Care Management (PCM) agencies must submit, as appropriate, when requesting prior authorization (PA) for PCA services. This documentation must be submitted along with the completed MassHealth Application for PCA Services (PCA-1) form, and the completed and signed MassHealth Evaluation for PCA Services (PCA-2) form. This documentation will assist MassHealth in determining medical necessity for PCA services and will facilitate the timely processing of PA requests. A PCM agency may also submit with the PA request any additional documentation that supports the consumer’s medical necessity for PCA services. This list of standard documentation is accessible through the MassHealth Web site at www.mass.gov/masshealthpubs. Documentation to include with a PA request CMS form 485 Home Health Certification and the Individualized Plan of Care or CMS form 487 Home Health Addendum — as appropriate Submit this documentation when The PCA consumer is receiving home health services, or the consumer’s home health services are being discontinued. See Section IV(a) of the PCA application. Why you need to include the documentation Used to determine what home health services the consumer is currently receiving, or was receiving, and to provide further information on any functional abilities or limitations of the consumer. Documentation to include with a PA request Department of Developmental Services (DDS) forms — copy of DDS Contract Summary Form and DDS PCA Referral Form, completed and signed by DDS and the PCM agency, where appropriate. If the consumer receives no DDS-funded residential supports, but is DDS-eligible and does not live with his/her parents, then submit a copy of the PCA Referral Form only. Submit this documentation when The PCA consumer is DDS-eligible, over the age of 21, and is receiving DDS-funded residential supports (less than 24/7) and is not living with his/her parents. Note: DDS consumers who receive DDS-funded residential supports on a 24/7 basis receive all personal care assistance through DDS. Therefore, personal care services would duplicate services provided through the residential supports contract and are not covered for such consumers. Why you need to include the documentation The DDS forms will be used to identify whether or not DDS-funded residential supports are provided to the consumer and to ensure that the requested PCA services are not duplicative of services provided by DDS. Documentation to include with a PA request Copy of the residential supports contract from the residential vendor or the state agency. Submit this documentation when The PCA consumer is not DDS-eligible but is receiving residential support services (24/7 or less than 24/7), funded by a state agency other than DDS, such as the Massachusetts Rehabilitation Commission (MRC), Department of Mental Health (DMH), or Department of Children and Families (DCF), etc. Why you need to include the documentation The residential support contract is used to determine whether or not the requested PCA services duplicate services provided through the residential supports contract. Documentation to include with a PA request Documentation on transportation to medical appointments — name of doctor/clinic, specialty, start location, city/town of medical appointment, frequency (monthly, quarterly, annual, etc.), and mode of transportation (bus, car, etc.). Include transfer time in and out of home and in and out of medical provider’s office. (This information can be included on the PCA evaluation form (PCA-2) or on a separate sheet.) Submit this documentation when The PCM agency is requesting time for the PCA to accompany the consumer to medical providers. Why you need to include the documentation Used to support the requested number of minutes for the PCA to accompany the consumer on medical appointments. Documentation to include with a PA request The date of discharge or the projected date of discharge from an inpatient facility Submit this documentation when The PCA consumer is being discharged from a nursing facility or other inpatient facility. Note: MassHealth cannot pay for PCA services while a consumer is in an inpatient facility. Why you need to include the documentation Used to determine when a consumer’s PA should take effect. The PCM agency must contact the PA Unit when it is submitting an initial PA request for a consumer being discharged from a facility. Contact the PA Unit at 1-800-862-8341 or via e-mail at PCAinfo@umassmed.edu with “Expedited Request Facility Discharge – Tracking #XXXXXXX” in the subject line. Documentation to include with a PA request The MassHealth adult foster care (AFC) provider’s discharge plan complete with date of discharge from the AFC provider agency or The MassHealth group adult foster care (GAFC) discharge summary report from the GAFC provider agency Submit this documentation when A MassHealth member who has been receiving MassHealth AFC or GAFC services has applied for PCA services. Note: A consumer cannot receive both PCA services and AFC or GAFC services. Why you need to include the documentation Used to document that the consumer will be discharged from AFC before PCA services start. Used to document that the consumer will be discharged from GAFC before PCA services start. Documentation to include with a PA request Hospice plan of care from the consumer’s hospice provider Submit this documentation when A PCA consumer has elected hospice and is either receiving, or has requested to receive, PCA services. Why you need to include the documentation PCM agencies must obtain the consumer’s hospice plan of care from the hospice provider and submit it to MassHealth in accordance with MassHealth PCA Bulletin 4, dated August 2009. Documentation to include with a PA request Documentation on instrumental activities of daily living (IADLs) for a consumer living with family members — Provide written justification for why the consumer’s family member(s) (as defined in 130 CMR 422.402) cannot provide the routine IADL assistance. Submit this documentation when The PCM agency is requesting time for IADLs, and the consumer lives with family member(s) (as defined in 130 CMR 422.402). Why you need to include the documentation 130 CMR 422.410(C)(1) states: “When a member is living with family members, the family members will provide assistance with most IADLs. For example, routine laundry, housekeeping, shopping, and meal preparation and clean-up should include those needs of the member.” The PCM agency must submit written justification that describes the consumer’s individual circumstances that prevent family members living with the consumer from providing physical assistance with IADLs. Documentation to include with a PA request Documentation to support verbal authorization of PCA services — as required by 130 CMR 422.416(A)(1)(d)(ii): “documentation that the nurse who conducted the evaluation obtained verbal authorization to initiate (or continue) PCA services from the member’s physician or nurse practitioner. Such documentation must include the member’s name and address, the name and telephone number of the nurse who obtained the authorization, the date the authorization was obtained, the number of PCA hours requested by the personal care agency and ordered by the physician or nurse practitioner, and the name, address, and telephone number of the physician or nurse practitioner who granted the authorization.” Submit this documentation when The PCM agency obtained verbal authorization from the MD or NP to initiate or continue PCA services and they have checked the box on page 6 of the evaluation form confirming that the written documentation will be provided within 60 calendar days. Why you need to include the documentation 130 CMR 422.416(A)(1) states “…Requests for prior authorization for PCA services must include: …documentation that the member’s physician or nurse practitioner has ordered PCA services.” If the PCM agency obtains verbal authorization from the consumer’s physician or nurse practitioner, the PCM agency must obtain the completed and signed physician/nurse practitioner sign-off page of the MassHealth evaluation form (PCA-2) within 60 calendar days of the date that the prior- authorization request to initiate (or continue) PCA services is sent to MassHealth, and maintain the physician/nurse practitioner sign-off page in the consumer’s file, making it available to MassHealth on request. Documentation to include with a PA request Documentation from Department of Children and Families (DCF) that includes the list of tasks approved by DCF’s Parent and Children Together (PACT) program and the time allowed for each task — The list of PACT tasks approved by DCF and the time allowed for each task is maintained in the consumer’s DCF case record. Contact the member’s local DCF office to obtain a copy of this list. Submit this documentation when A PCA consumer receives foster care provided through DCF and the foster parent receives supplemental payment through DCF’s PACT program to provide care beyond what an average child requires. This may include assistance with ADLs. Why you need to include the documentation To ensure no duplication of services between the list of PACT tasks and the ADLs or IADLs requested for PCA. Documentation to include with a PA request Documentation from Neighborhood Health Plan (NHP) that includes the DCF Individual Care Plan, list of all services being utilized (including continuous skilled nursing); who is providing each service; schedule of when the services are being provided to the consumer; and name and contact information for the nurse practitioner approving the service and providing case management for the consumer if needed. To obtain this documentation, contact Neighborhood Health Plan: Priscilla Meriot at 1-888-897-8947 or e-mail: Priscilla_Meriot@NHP.org You must provide a copy of the consumer’s authorization to release information. Submit this documentation when The PCA consumer is enrolled in Special Kids/Special Needs program (SKSN), a program cosponsored by the DCF and MassHealth. Children in SKSN are in the custody of DCF, are living in foster homes, and have special health-care needs. Neighborhood Health Plan is under a contract with MassHealth to provide for a full range of medical services to be delivered in the child’s foster home or other appropriate settings when medically necessary. This may include assistance with ADLs and IADLs. The MassHealth Prior Authorization Unit (PAU) maintains a list of all children enrolled in SKSN. PCM agencies can e-mail the PAU at PCAinfo@umassmed.edu to find out if a child is enrolled in SKSN. Why you need to include the documentation To ensure no duplication of services between the services provided under the Special Kids/Special Needs Program (SKSN) and PCA services. PCA-SD (06/11)