Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceUCare home health prior auth form Coverage | OpenP…
    Ask Trek AI about this page
    CurrentUCarePolicy N/A

    Home health and home infusion pre-certification/authorization form coverage criteria

    Customize your policy alerts

    Sign up for all UCare policy alerts

    Know when UCare releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This document governs pre-certification and authorization requests for home health, home infusion, MDO, or AIC services submitted to CARECONTINUUM on behalf of UCare members; it affects ordering prescribers, billing providers, and suppliers seeking coverage. It specifies the information providers must supply for review and may require prescriber review for certain requests.

    Policy Summary
    PayerUCare
    PolicyHome health and home infusion pre-certification/authorization form coverage criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit a completed authorization form with J/HCPCS code, dose, route, frequency, dates, ICD-10 diagnosis, and supporting documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7distinct form sections
    J/HCPCSdrug identifier fields requested

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Member/Patient
    patient identification requested
    Signature reqprescriber attestation

    Coverage and Authorization Requirements

    Authorization completeness criteria

    Covered when required authorization form is completed with all the following information:

    Required form elements: Urgency indicator; complete patient demographics (member ID, group number, patient name, date of birth, street address, city, state, ZIP); clinic/billing provider data (clinic name, NPI, billing provider relationship to prescriber); prescriber name, NPI or DEA, office contact and phone, prescriber address, and prescriber signature/attestation; requested drug details (request type: new or renewal; drug name; J‑code and/or HCPCS code; dose; frequency; route; start and end dates); diagnosis with ICD‑10‑CM code(s); patient weight and height; place of service; statement of medical necessity including clinical and treatment history, current therapy status, medications and adverse effects; and supporting documentation (office notes, medical records, or other described attachments).

    All fields referenced must be completed and legible for the request to proceed with review.

    Operational note: Incomplete or illegible information may delay the review process and could result in denial of the request.

    If any required element is missing or illegible, CARECONTINUUM may refuse or delay processing until complete information is provided.

    The form does not list specific clinical exclusions; however, any required information that is incomplete or illegible may delay review and could result in refusal or denial. Providers should ensure all fields are completed and readable before submission to avoid processing delays.

    There is no explicit list of conditions deemed Not Medically Necessary on the form. Coverage determinations regarding medical necessity are made after review of the submitted clinical information and, when appropriate, consultation with the prescribing physician.

    Billing and Diagnosis Codes

    Requested drug billing codesHCPCS
    J CodeRequested Drug J Code field (as provided by submitter)
    HCPCS CodeRequested Drug HCPCS Code field (as provided by submitter)
    Diagnosis codesICD-10
    ICD-10 CMDiagnosis code(s) field — submit appropriate ICD-10-CM codes

    What the Ordering Provider / Supplier Must Do

    Prior Authorization

    Prior authorization required — include J/HCPCS, dosing, route, frequency, dates

    Prior authorization is required for home infusion and certain home health drug services. Submit the completed authorization form with the requested drug billing identifier (J Code or HCPCS), drug name, dose, route, frequency, start and end dates, diagnosis (ICD-10-CM), and patient weight/height so CARECONTINUUM can process the request.

    • Include J Code or HCPCS Code field as provided by submitter
    • Provide dose, frequency, route, start date and end date
    • Include diagnosis ICD-10-CM code(s) and patient weight/height
    Note

    Submit completed form and expect prescriber review when required

    Fax the completed form to the number listed on the form and be prepared for CARECONTINUUM to contact the prescribing physician for review when required; answer all form questions to avoid processing delays.

    • Select Request Type: New Request or Renewal of Previous Approval

    Form Options and Request Types

    Place of Service
    HomePlace of Service option for services delivered at the patient’s residence.
    Physician's OfficePlace of Service option for services provided in the prescribing clinician’s office.
    Hospital OutpatientPlace of Service option for services delivered in a hospital outpatient department.
    Ambulatory Infusion SuitePlace of Service option for services delivered in an ambulatory infusion suite.
    Request Type
    New RequestSelect when submitting an initial authorization request for this therapy or service.
    Renewal of Previous Approval

    Policy Purpose and Scope

    This authorization form is intended to capture the clinical and administrative details needed to determine medical necessity for home health, home infusion, MDO, or AIC services. It requests treatment history, current therapy status, prescriber and billing information, drug identifiers and dosing, place of service, and supporting documentation so CARECONTINUUM can review requests and consult the prescribing physician when required.

    Policy Summary
    PayerUCare
    PolicyHome health and home infusion pre-certification/authorization form coverage criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit a completed authorization form with J/HCPCS code, dose, route, frequency, dates, ICD-10 diagnosis, and supporting documentation.
    SourceLink
    On This Page
    Coverage and Authorization RequirementsBilling and Diagnosis CodesWhat the Ordering Provider / Supplier Must DoForm Options and Request TypesPolicy Purpose and Scope
  1. Indicate Place of Service (Home, Physician's Office, Hospital Outpatient, Ambulatory Infusion Suite)
  2. Provide directions and statement of medical necessity
    3. Documentation Required

    Required clinical documentation — narrative and supporting records

    Provide a medical necessity narrative and supporting clinical records: include clinical and treatment history, current medications, adverse effects or conditions, and enclose office notes or other medical records as applicable.

    • Medical necessity (clinical and treatment history)
    • List of current medications and any adverse effects
    • Enclose Office Notes, Medical Records, or Other supporting documentation
    Billing Rule

    Administrative & prescriber information — provide complete demographics, clinic, and prescriber details

    Provide complete patient/member demographics, clinic and billing provider details, and full prescriber information including NPI or DEA and prescriber signature; include office contact and contact phone/fax/email as available.

    • Member Identification Number, Group Number, patient name, DOB, address, and phone numbers
    • Clinic name, NPI, billing provider indication, clinic address, phone, fax, email
    • Prescriber name, NPI or DEA number, office contact and phone, prescriber signature
    Denial Risk

    Risk of delay or denial for incomplete/illegible information

    Any information left blank or that is illegible may delay the review process and could result in denial of the request; ensure all required fields on the form are completed legibly before faxing.

    • Incomplete or illegible submissions can be refused or delayed
    • Verify all required form fields are completed to proceed with review
    Select when requesting continuation or extension of an existing prior authorization.