July 10, 2006

HP-06-09

HHA-06-09

All Blue Cross Contracting Home Health Agencies and Hospice Agencies

Prior Authorization of Services

Some home health and hospice agencies are not obtaining prior authorization for the services they provide to BCBS members even though it’s a requirement of the BCBSKS contracting provider agreement.

Many times when we ask providers why prior authorization isn’t being requested, we’re told that:

• Your staff is too busy providing patient care and they just don’t have time, 
• Your staff thought someone else in your office handled it, or
• Your staff forgot. 

While we have a great regard for the care you provide and certainly understand busy schedules, the bottom line is, prior authorization of home health and hospice services is a requirement of the contracting provider agreement.  It needs to be obtained prior to the start of care and continue until the patient no longer requires services. 

The prior authorization process also gives you upfront knowledge of the member’s benefits and the predictability of what you’ll get reimbursed.  Based on the provider contract, if you fail to prior authorize, the allowance for the covered services you provide will be reduced by 25% (maximum penalty of $250 per treatment episode).  

A member’s contract may not cover home health or hospice services but may include a benefit for private duty nursing (PDN). Sometimes BCBSKS can use or “flex” the PDN benefit and apply it to home health or hospice services.  Private duty nursing services do not require prior authorization but if we’re using the PDN benefit to allow payment for home health or hospice services, the home health or hospice services must be prior authorized.

When BCBSKS receives a claim for services that have not been authorized, it is returned to the provider asking for the medical records.  This not only increases your administrative time but also delays your payment.

Prior authorization can be requested by calling 1-800-782-4437.  Remember that:

• All home health and hospice services for BCBSKS members must be prior authorized.
• Prior authorization is a requirement of the provider contract regardless of the requirement under the member contract.
• Authorization should be obtained prior to the start of care.
• If after providing the authorized services, the patient requires additional care, you must also prior authorize the additional visits. 
• You should continue to request prior authorization until the patient no longer requires services.
• Failure to obtain prior authorization results in a 25% penalty that is a provider write-off.

For more information, refer to the Home Health Agency and Hospice sections of the BCBSKS Institutional Provider Manual available on the BCBSKS Web site at: http://www.bcbsks.com/CustomerService/Providers/publications/institutional/manuals/inst_rel_man.htm.

Drb