Prior Authorization Process: Initial and Extended Prior Authorizations
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Governs prior authorization requirements and procedures for initial and extended Home Health services for Montana Medicaid; applies to Home Health Agencies (HHAs) and the Department's Utilization Review Contractor.
No material clinical or coverage changes in this revision.
Prior Authorization and Coverage Criteria
Prior authorization criteria for Home Health services
Prior authorization coverage is granted when required forms and documentation are submitted to the Contractor and clinical need is established; limits and documentation requirements apply as follows.
ALL of the following
ALL of the following
- Documentation: Submit SLTC 124 (Request for Initial Prior Authorization and Amendment) and a signed SLTC 126 (Home Health Certification and Plan of Care).
- Limits: Home Health services are limited to 180 visits within 365 days of the initial service visit.
- Timing: The provider must request authorization within 5 business days from the initial visit.
ALL of the following
- Requirements: Submit SLTC 124 notating amendment and two nursing/therapy visit notes.
ANY of the following
- If more than 60 days has elapsed since the last physician certification date, include a signed SLTC 126 (Home Health Certification and Plan of Care).
- If 60 days or fewer have elapsed since last certification, SLTC 126 is not required for the amendment request (physician certifications may cover a period of less than but not greater than 60 days).
ALL of the following
- Requirements: Submit SLTC 125 (Request for Prior Authorization for Extended Services), a current SLTC 126, and two nursing/therapy visit notes each time an extension is requested.
- Timing: Requests for extended services must be submitted no later than 14 business days before the 180-visit limit is reached to assure timely approval.
- Limits: Each approved extension will have an authorized date span not to exceed 60 days.
- If approved: Contractor will generate a new authorization number for billing; if denied: Contractor will notify the requesting HHA. The Department will not backdate prior authorization requests.
ALL of the following
- The Contractor will enter authorization numbers into MMIS and MMIS will send the prior authorization number to the HHA.
- If a request (initial, amendment, or extension) is denied, the Contractor will notify the requesting HHA.
Visit Limits, Authorization Spans, and Codes
Provider Responsibilities and Authorization Workflow
Prior authorize all Home Health services through the Contractor
All Home Health services must be prior authorized through the Department's Utilization Review Contractor before services are delivered. Medicaid payments made for unauthorized services may be recoverable and the Department will not back date prior authorizations.
Submit initial authorization within 5 business days of first visit
Request initial prior authorization within five business days from the member's initial Home Health visit.
Amend initial authorization with SLTC 124, two visit notes, and SLTC 126 when required
To amend an initial authorization to add visits, submit SLTC 124 notating the amendment plus two nursing or therapy visit notes; if more than 60 days have passed since the last physician certification, also submit a signed SLTC 126.
- SLTC 124 (Request for Initial Prior Authorization and Amendment) notating amendment
- Two nursing/therapy visit notes
- Signed SLTC 126 (Home Health Certification and Plan of Care) if >60 days since last physician certification
Request extended services with SLTC 125, SLTC 126, two visit notes, and timely submission
When the 180-visit limit is reached, request extended services by submitting SLTC 125, a current SLTC 126, and two nursing/therapy visit notes; submit the request no later than 14 business days before the 180‑visit limit is reached. Extended authorizations will have an authorized date span not to exceed 60 days and each approved extension receives a new authorization number.
- SLTC 125 (Request for Prior Authorization for Extended Services)
- Current SLTC 126 (Certification and Plan of Care)
- Two nursing/therapy visit notes
- Submit no later than 14 business days before the 180-visit limit is reached
- Authorized date span for each extension not to exceed 60 days
- A new authorization number is generated for each approved extension
Contractor will notify HHA of denial
If a prior authorization request is denied, the Contractor will notify the requesting Home Health agency (HHA).
Contractor enters authorization numbers into MMIS and MMIS sends them to HHA
The Contractor will enter approved authorization numbers into the State's Medicaid Management Information System (MMIS); MMIS will then send the prior authorization number to the Home Health agency (HHA).
Definitions and Required Forms
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