CurrentKaiser PermanentePolicy HCS-06-1008

Clinical Review Criteria — Home Care Services

Defines clinical review criteria and authorization framework Kaiser Permanente uses to determine medical necessity for home health services for members of Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Home Care Services

Policy CodePolicy HCS-06-1008

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify prior authorization requirements by plan type using payer resources before providing home health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MCG-basedNon-Medicare source

Medicare ManualMedicare source

NoneCodes listed

WAApplicable plans

Coverage Determinations and Sources

Source-based criteria

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Home Care Services

Policy CodePolicy HCS-06-1008

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify prior authorization requirements by plan type using payer resources before providing home health services.

SourceLink

On This Page

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Medicare members: Use CMS Coverage Manuals (Medicare Benefit Policy Manual Chapter 7 Home Health Services) to determine Medicare home health benefit eligibility and criteria.

Source: CMS Coverage Manuals (Medicare Benefit Policy Manual Chapter 7)

Non-Medicare members: Kaiser Permanente uses MCG Home Care Guidelines for medical necessity determinations for non‑Medicare members; MCG guidelines are proprietary and may be requested for an individual member by contacting Kaiser Permanente Clinical Review staff or accessing the MCG Guideline Index through the provider portal.

Source: MCG Home Care Guidelines (proprietary)

Background context: Admission criteria are based on federal Medicare home health benefit regulations; background literature cited in the document is for informational purposes and is not to be used as coverage criteria.

Background reference

The MCG Home Care Guidelines referenced for non‑Medicare medical necessity determinations are proprietary. MCG guidelines are proprietary and cannot be published and/or distributed. Providers may access the MCG Guideline Index via the provider portal under Quick Access, or request the specific MCG criteria used for an individual member’s utilization decision by calling Kaiser Permanente Clinical Review staff at 1-800-289-1363.

These Clinical Review Criteria are intended to assist in administering plan benefits and do not guarantee coverage. Coverage is subject to the member’s Evidence of Coverage, plan contract terms, and medical necessity determinations. Kaiser Permanente reserves the right to modify or revoke these criteria and providers should always consult the patient’s Evidence of Coverage or call Kaiser Permanente Member Services to determine coverage for a specific service.

Provider Responsibilities and Authorization

Prior Authorization

Verify Prior Authorization per Plan

Authorization requirements vary by plan. Providers must verify prior authorization and specific authorization requirements using payer resources (provider portal or member services).

Verify authorization via the provider portal or call Kaiser Permanente Member Services at 1-888-901-4636 (TTY 711), Monday–Friday, 8 a.m.–5 p.m.

Note

Service Role Note

Social Work is considered a secondary service and not a primary service.

Note

MCG Criteria Access

For non‑Medicare members, Kaiser Permanente uses the MCG Home Care Guidelines for medical necessity determinations. MCG guidelines are proprietary and cannot be published; providers may request the specific MCG criteria used for an individual utilization management decision by calling Kaiser Permanente Clinical Review staff at 1-800-289-1363 or accessing the MCG Guideline Index through the provider portal under Quick Access.

MCG criteria available on request for individual member reviews via Clinical Review staff: 1-800-289-1363
Access MCG Guideline Index through the provider portal under Quick Access

Note

Coverage Dependent on Contract

Coverage determinations depend on the member's contract and Evidence of Coverage. Providers should verify the member's EOC and plan documents to determine whether services are covered under the member's specific contract.

Contact Member Services or review the member's Evidence of Coverage to confirm benefit availability and any plan-specific limitations.

Policy Background

The criteria for admission to home health services are based on federal Medicare regulations and supplemental sources. For Medicare members, eligibility and coverage criteria follow the CMS Coverage Manuals (Medicare Benefit Policy Manual Chapter 7 Home Health Services). For non‑Medicare members, Kaiser Permanente uses the proprietary MCG Home Care Guidelines for medical necessity determinations; providers may request the specific MCG criteria used for a utilization decision. The document provides background references used to develop the criteria but directs providers to the CMS manuals, the MCG guidelines, and the member’s Evidence of Coverage for final determinations.

Key Definitions

Admission criteria

Regulatory basisAdmission criteria are based on federal Medicare home health benefit regulations (CMS Home Health benefit).

Application to Medicare membersUse CMS Coverage Manuals (Medicare Benefit Policy Manual Chapter 7) to determine Medicare home health benefit eligibility and criteria.

Application to non‑Medicare membersFor non‑Medicare members, Kaiser Permanente uses MCG Home Care Guidelines for medical necessity determinations (MCG is proprietary and available on request).

Provider actionProviders should verify plan-specific authorization requirements and consult payer resources or Clinical Review staff for MCG criteria when applicable.

OpenPayer

Clinical Review Criteria — Home Care Services

Coverage Determinations and Sources

Applicable Procedure and Billing Codes

Provider Responsibilities and Authorization

Policy Background

Key Definitions