Home health and home infusion pre-certification/authorization form coverage criteria
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This document is a pre-certification and authorization request form used by CARECONTINUUM for home health, home infusion, MDO, or AIC services and applies to providers requesting coverage through Aspirus Arise. It collects patient, clinic, prescriber, and requested drug/service information to support utilization review.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization Criteria
Covered when ALL of the following are provided and reviewed:
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The form indicates that some coverage requests may require direct review with the prescribing physician as part of the authorization process. Providers should complete and fax the pre-certification/authorization form to CARECONTINUUM with legible and complete patient, clinic, prescriber, and requested service/drug information so the request can be reviewed and any necessary follow-up with the prescriber can occur.
The form does not list specific conditions that are automatically considered "not medically necessary." Instead, determinations about medical necessity will be made after the submitted information is reviewed; incomplete or illegible entries may delay that review.
Requested Codes and Billing Information
| J Code | Requested drug J-code (as provided by requester) |
| HCPCS Code | Requested HCPCS code (as provided by requester) |
| ICD-10-CM | Diagnosis code(s) for the request |
| Drug Name | Name of the requested drug |
| Dose | Requested dose |
| Frequency | Requested dosing frequency |
| Route | Route of administration |
| Start Date | Requested start date |
| End Date | Requested end date |
| Patient Weight | Patient weight |
| Patient Height | Patient height |
Provider Actions and Submission Requirements
Pre-certification/Authorization Required
Complete and fax the CARECONTINUUM pre-certification/authorization form for home health, home infusion, MDO, or AIC services. The form must include legible entries for patient, clinic, prescriber, requested drug/service (including Drug Name, J Code or HCPCS Code), dose, frequency, route, start and end dates, and ICD-10 diagnosis code(s).
- Fax the completed form to the CARECONTINUUM number shown on the form.
- Provide requested drug information fields: Drug Name, J Code, HCPCS Code, Dose, Frequency, Route, Start Date, End Date.
- Include diagnosis: ICD-10-CM diagnosis code(s).
Complete all selection fields and describe 'Other' when indicated
Ensure all required fields on the form are completed and clear; where the form asks to select request type, place of service, and whether the patient is currently established on therapy, choose the appropriate options and provide any additional details requested under 'Other'.
- Select Request Type: New Request or Renewal of Previous Approval.
- Select Place of Service: Home, Physician's Office, Hospital Outpatient, or Ambulatory Infusion Suite.
- If 'Other' documentation is indicated, describe the documents in the space provided.
Required Supporting Documentation
Include supporting clinical documentation with the request as indicated on the form to demonstrate medical necessity, such as office notes, medical records, and any other relevant records.
- Enclose Office Notes when selected.
- Enclose Medical Records when selected.
- Provide any Other described documentation requested on the form.
- Include a medical necessity statement with clinical and treatment history (medications, adverse effects, and conditions).
Incomplete or Illegible Information May Delay or Jeopardize Review
Do not submit forms with blank, missing, or illegible information; incomplete or illegible entries may delay the review process and could result in denial or delayed authorization.
- Verify all patient, clinic, prescriber, and requested service/drug information is legible before faxing.
- Answer required questions (e.g., urgency, request type, place of service) to avoid processing delays.
Definitions and Place of Service
Background
This pre-certification/authorization form is designed to gather medical necessity information and treatment history—such as current medications, adverse effects, clinical rationale, and relevant dates—to support utilization review and authorization decisions for home-based services or infusion therapies. Complete, legible clinical details and supporting documentation enable CARECONTINUUM to evaluate the request and, when needed, consult the prescribing physician.
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