Skilled home health nursing services pre-certification
This policy governs pre-certification medical necessity review of skilled nursing and related home health services for Anthem fully insured health plans, affecting ordering and servicing providers who submit requests for dates of service on or after January 1, 2018.
Effective with dates of service on and after January 1, 2018, Anthem will review the skilled nursing home health services noted below for medical necessity as a pre-certification for fully insured plans.
Coverage Criteria
Pre-certification applicability
Covered when ALL of the following are met
Pre-certification medical necessity review required
This pre-certification requirement applies to Anthem fully insured health plans for dates of service on or after January 1, 2018. The policy governs medical necessity review of the specified skilled nursing and home health services when all applicability conditions are met: the service is one of the skilled nursing or home health services listed in the policy, the member is covered under an Anthem fully insured plan, and the date of service is on or after the effective date. This program does not apply to Medicare, Medicaid, National Accounts, BlueCard, or the Federal Employee Program (FEP).
Anthem will perform a medical necessity review as a pre-certification for the specified skilled nursing home health services. Ordering and servicing providers may submit pre-certification requests by contacting the phone number on the back of the member’s ID card. The clinical guideline CG-MED-23 applies to home health services referenced by this policy. This program does not change existing authorization processes for in-home physical, occupational, or speech therapy, Home Infusion Centers, or Private Duty Nursing.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.