CurrentAnthemPolicy N/A

Home Health wound care update

Applies to Anthem members in Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect; updates requirements effective March 1, 2020 for clinical documentation, prior authorization frequency, face-to-face timing, and plan-of-care revision for home health wound care services.

Policy Summary

PayerAnthem

PolicyHome Health wound care update

Policy CodePolicy N/A

Change TypeDocumentation and authorization requirements added

Effective DateMar 1, 2020

Next Review DateN/A

Key ActionSubmit a prior authorization (PA) for wound care every 8 weeks with required clinical documentation; incomplete requests will be returned.

SourceLink

POLICY UPDATE CHANGES

Effective March 1, 2020 Anthem requires all wound care requests to include current clinical documentation demonstrating medical necessity.

Providers must submit a prior authorization every 8 weeks when performing wound care.

Face-to-face encounter timing defined as no more than 90 days before or 30 days after start of services.

Revised plan-of-care required for every change request in home health visits.

Directs providers to use the Indiana Health Coverage Programs Universal Authorization Form and provides fax and electronic submission methods.

8Required documentation elements (high-level)

8Weeks between required prior authorizations

90/30

Face-to-face timing window (days before/after)

What is changing

Anthem updated documentation and authorization requirements for home health wound care for Indiana Medicaid programs. Applies to Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect. Effective 2020-03-01. has_material_change: true.

Key thresholds and statistics

Face-to-face windowNo more than 90 days before or 30 days after start of services

Prior authorization frequencySubmit a prior authorization every 8 weeks when performing wound care

Required documentation elements (high-level)8

Weeks between required PAs8

Face-to-face timing window90/30

Programs affected: Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect. Effective date: 2020-03-01.

Required documentation for wound care plan of care (POC)

Requests for wound care must include current clinical documentation demonstrating medical necessity; requests without the below may adversely affect outcome.

ALL of the following

Date the patient was last seen by the primary medical provider (PMP) and/or specialist for the wound(s)
The start date of wound treatment
Accurate diagnostic information that pertains to the underlying diagnosis and condition as well as any other medical diagnoses and conditions, including the patient's overall health status
Examples of diagnostic detail

Timing and prior authorization requirements for home health wound care

ALL of the following

Face-to-face encounter must occur no more than 90 days before or 30 days after the start of services to initiate home health services
Providers will submit a prior authorization (PA) every 8 weeks if performing wound care
A revised POC is required for every change request in home health visits and must include all continuing and new orders and document any changes in the patient's condition or diagnosis

Authorization form and submission

ALL of the following

Use the Indiana Health Coverage Programs PA form (Universal Authorization Form) located on Anthem provider website for service requests
The form must be complete with all supporting clinical documentation; requests without required documentation will be returned as incomplete
Fax PA requests with required clinical information to 1-844-765-5157 or submit electronically via Availity (https://www.availity.com)

Billing Rule

Background and definitions

Background: Anthem updated requirements for documentation and authorization of home health wound care for members in Indiana Medicaid programs and references clinical guideline CG-MED-71. Last review date: 2019-12-01.

Term	Definition
POC
Plan of care
PMP
Primary medical provider

Policy update changes

2019-12-01review

Policy last reviewed.

2020-03-01material_changeLatest

Effective March 1, 2020 Anthem requires all wound care requests to include current clinical documentation demonstrating medical necessity; requests without required documentation may adversely affect the outcome.

2020-03-01material_changeLatest

Policy Summary

PayerAnthem

PolicyHome Health wound care update

Policy CodePolicy N/A

Change TypeDocumentation and authorization requirements added

Effective DateMar 1, 2020

Next Review DateN/A

Key ActionSubmit a prior authorization (PA) for wound care every 8 weeks with required clinical documentation; incomplete requests will be returned.

SourceLink

On This Page

Off-loading pressure and good glucose control for a patient who has a diabetic ulcer

Adequate circulation present for a patient who has an arterial ulcer

Patient's pertinent current and prior functional limitations and activities

Any nutritional deficits or needs required for the patient

Dose and frequency of any medications

Description of wound

Weekly wound measurements, which include length, width, depth, any tunneling and/or undermining
Wound color, drainage (type and amount) and odor, if present

Wound treatment documentation

Describe current prescribed wound care regimen, including frequency, duration and supplies needed
Describe all previous wound care therapy regimens if appropriate
If an infection is present, describe the current treatment regimen
If wound debridement is prescribed, documentation must support the level and number of debridements
Documentation should indicate if the debridement involves muscle or bone
Provide evidence of maintaining a clean, moist bed of granulation tissue

Equipment used for wound treatment (if applicable)

Use of pressure-reducing support surface, mattress and/or cushion
Use of compression system (e.g., for patients with venous ulcers)

Documentation Required

Comprehensive wound care documentation required

Include comprehensive wound-care clinical documentation demonstrating medical necessity when submitting wound care requests.

Date patient was last seen by the PMP and/or specialist for the wound(s)
Start date of wound treatment
Accurate diagnostic information (underlying diagnosis, overall health status)
Patient's current and prior functional limitations and activities
Any nutritional deficits or needs
Dose and frequency of any medications
Weekly wound measurements (length, width, depth, tunneling/undermining)
Wound characteristics: color, drainage (type/amount), odor (if present)
Current prescribed wound care regimen and supplies (frequency, duration)
Description of previous wound care regimens, if appropriate
Infection treatment regimen, if infection present
Debridement level and number with indication if muscle or bone involved
Evidence of maintaining a clean, moist bed of granulation tissue

Documentation Required

Revised plan-of-care required for change requests

Submit a revised plan of care for every home health change request that documents continuing and new orders and any changes in condition or diagnosis.

Revised POC must include all continuing and new orders
Revised POC must document changes in the patient's condition or diagnosis

Prior Authorization

Prior authorization every 8 weeks

Submit a prior authorization every 8 weeks when performing wound care, including required clinical documentation.

Incomplete requests without required clinical documentation will be returned
Include the comprehensive documentation elements listed in the POC requirements

Documentation Required

Face-to-face encounter timing requirement

Ensure the face-to-face encounter occurs no more than 90 days before or 30 days after the start of home health services.

Face-to-face timing threshold: no more than 90 days before or 30 days after start of services

Authorization form and submission channels

Use the Indiana Health Coverage Programs Universal Authorization Form and submit complete PA requests via the specified fax or electronically via Availity.

Fax: 1-844-765-5157
Electronic: Availity (https://www.availity.com)
Incomplete or missing required clinical documentation will be returned

What authorization form to use: Use the Indiana Health Coverage Programs Universal Authorization Form on Anthem's provider website; fax to 1-844-765-5157 or submit via Availity.

Where to find guideline CG-MED-71: Visit Anthem provider website, select Medical Policies and Clinical UM Guidelines Search, and enter CG-MED-71.

Providers must submit a prior authorization (PA) every 8 weeks when performing wound care.

2020-03-01material_changeLatest

To initiate home health services, the face-to-face encounter must occur no more than 90 days before or 30 days after the start of services.

2020-03-01material_changeLatest

A revised plan-of-care (POC) is required for every change request in home health visits and must include all continuing and new orders and document any changes in the patient's condition or diagnosis.

2020-03-01administrative

Use the Indiana Health Coverage Programs Universal Authorization Form for PA requests; complete form with supporting clinical documentation and submit via fax to 1-844-765-5157 or electronically via Availity; incomplete requests will be returned.

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