Personal Care Assistant (PCA) Services
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Defines conditions under which MedStar Family Choice District of Columbia may authorize PCA services for eligible DC Healthy Families enrollees; specifies prior authorization, documentation, and service limits. Does not cover DC Healthcare Alliance enrollees.
Changed policy number from 1414.DC to 182.DC and updated responsible parties to titles only.
Added Manager, Case Management and Manager, Special Populations Case Management to responsible parties.
Updated procedures including edits to submission steps and added routing after the form is signed; removed some prior requirements such as initial three-month authorization.
Aides must verify personal care services/visits via Electronic Visit Verification (EVV) for reimbursement.
Coverage Criteria for PCA Services
Initial Eligibility and Authorization
Covered when ALL of the following are met:
PCA may assist with some Instrumental ADLs (IADLs).
MedStar PA team will notify the HHA of the authorization and provide the completed Level of Care (LOC).
Service Limits and Exclusions
Coverage limits and operational rules:
Claims for PCA hours provided during any hour in which the enrollee was receiving ADHP or similar concurrent services will be denied.
PCA services are not intended to cover general chore/homemaker duties.
Care Management Requirements
Ongoing care management requirements:
An RN may assess the enrollee if condition changes without need for additional authorization.
EVV is required to ensure reimbursement of aide visits.
Not a covered benefit for DC Healthcare Alliance enrollees. PCA services are available only to DC Healthy Families enrollees; enrollment in the DC Healthcare Alliance program disqualifies the member from PCA coverage under this policy. Additionally, PCA services do not include chores or homemaking tasks that are unrelated to the enrollee’s health or nutrition. Examples of excluded tasks include shopping for items not directly related to the enrollee’s nutritional status or health needs and cleaning areas of the home not occupied by the enrollee.
Claims for PCA services billed for any hour during which the enrollee was receiving Adult Day Health Program (ADHP) or other similar services that provide personal care will be denied. When an enrollee receives both ADHP and PCA services on the same day, the combined authorized time for both services shall not exceed 12 hours per day; hours during which ADHP or overlapping services occur will not be payable for PCA.
Provider Actions and Authorization Workflow
Prior Authorization required; routing after practitioner signs POF
Prior Authorization is required for PCA services. After the enrollee's treating practitioner (physician/APRN) signs the Prescription Order Form (POF), the form is routed to MedStar Family Choice DC's contracted assessor who completes an interRAI assessment and forwards the assessment and pertinent medical records to the MedStar PA department for review and determination; the PA team then notifies the Home Health Agency of the authorization and provides the completed Level of Care (LOC).
- POF must be submitted via the Department of Healthcare Finance (DHCF) portal.
Reauthorization requires new POF
If PCA services are needed beyond the initial authorization period, the provider must submit a new Prescription Order Form (POF) to obtain continued authorization.
Submit request with supporting clinical info and signed POF
Requests must be submitted by the requesting practitioner (or MedStar practitioner/Home Health Agency/facility) with supporting clinical information and a signed Prescription Order Form (POF) submitted via the DHCF portal; the contracted assessor will complete an interRAI assessment and submit it with all pertinent medical records to the MedStar PA department.
- POF form is available on the DHCF website (POF V9).
- Submission channel: DHCF portal.
Monthly clinical notes and EVV verification required
Home Health Agencies must submit monthly clinical notes to the MCO; aides are required to verify personal care services/visits via the Electronic Visit Verification (EVV) system for reimbursement.
- Registered Nurse (RN) supervision is required at least monthly and RN may assess the enrollee if condition changes without additional authorization.
Claims for PCA during ADHP or similar services will be denied
Claims for PCA services provided during any hour in which an enrollee was receiving Adult Day Health Program (ADHP) services or other similar services in which PCA services are provided concurrently will be denied and are not payable.
- When ADHP and PCA are provided on the same day, combined services cannot exceed 12 hours per day.
Definitions
Background
Personal Care Assistant (PCA) services provide hands-on assistance with an enrollee’s Activities of Daily Living (ADLs) — including bathing, dressing, mobility, transferring, toileting, and eating — and may include assistance with certain Instrumental Activities of Daily Living (IADLs) when related to the enrollee’s care needs. Eligibility requires that the enrollee be unable to perform one or more ADLs and have a diagnosis consistent with debility that necessitates PCA support. Requests must be initiated by an in‑network contracted practitioner and submitted with supporting clinical information and a signed Prescription Order Form (POF) via the DHCF portal; the contracted assessor completes an interRAI assessment and forwards records to MedStar’s prior authorization team for determination.
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