Home Health – Universal MCO Forms

1. Home Health – Universal MCO Forms Presented by: BlueCare Tennessee, Amerigroup and UnitedHealthcare

2. Objectives • Overview of need for documentation • Review Universal MCO Home Health Agency Forms, and for each: • Provide purpose • Discuss documentation content • Discuss submission time frames

3. Our Goal Assure the provisions of medically necessary and appropriate health care to all TennCare members in the most cost-effective manner within the TennCare benefit structure. • Provide overview of contractual updates • Explain the purpose of each form • Give information on how the form supports member, home health agency and contractual needs • Supply instructions on who can complete each form • Offer a reference tool for each form (Appendix)

4. MCO Universal Forms • Home Health Agency Plan of Care Agreement (BlueCare Tennessee) • Home Health Agency Initial Member/Caregiver Training Checklist (UnitedHealthcare) • Home Health Agency Recertification Member/Caregiver Training Checklist (UnitedHealthcare) • Home Health Agency Plan of Care Form (Amerigroup)

5. BlueCare Tennessee Presented by: Tracy L. Curtis, MHA, BSN, RN, CCM BlueCare Tennessee Home Health Manager

6. Contractual Updates • Division of TennCare requirements • Condition of participation • Transfer and discharge • Backup plan and documentation

7. Home Health Agency Plan of Care Agreement Letter

8. Plan of Care Agreement: Purpose • Expectations • Member • Caregivers • Home Health Agency • Identify • Primary caregiver (unpaid) • Backup caregivers (unpaid) • Backup plan

9. Plan of Care Agreement: Instructions • Initiation of Service • “Meet and Greet” • Intake Visit • Submit via fax to MCO • With prior authorization request OR • As additional clinical post-intake visit • Upon resumption of care when necessary • Annually

10. UnitedHealthcare Presented by: Orlando Hayle VP, FIDE/DSNP Clinical Operations

11. Initial Member/Caregiver Training Checklist AND Recertification Member/Caregiver Training Checklist

12. What’s the value? To ensure in review of the member’s PDN POC that the appropriate training and teaching activities are reasonable and necessary to the goals and treatment of their condition Encourage and empower caregivers and members in self-care Back-up plans are documented and supported by confident caregivers

13. Differences between the forms There are two forms associated with the Member/Caregiver training Initial Member/Caregiver Training Checklist • Submitted within 60 days of an initial PDN approval • Only submitted for new services Recertification Member/Caregiver Training Checklist • The Initial Member/Caregiver training form is a pre-requisite • Submitted on all recertification or service continuations • Reviewed and submitted annually • Submitted upon training and caregiver changes

14. When to submit the forms Initial Member/Caregiver Training Checklist • Included with all initial prior authorization requests Recertification Member/Caregiver Training Checklist • Included with all authorization recertification • Submitted annually • Included with all authorization related to change in conditions • Submitted with new training due to change in condition • Submitted when new caregivers are added as a natural support and included in the back-up plan

15. Submission expectations Member’s subscriber ID Date of birth Date List of all care tasks supported by member/caregiver Completed member/caregiver/agency signatures

16. Amerigroup Presented by: Stephanie McNeal, RN Manager II GBD Specialty Programs

17. Agency Plan of Care

18. Agency Plan of Care FormPurpose • Provide a comprehensive individualized plan of care for members receiving Private Duty Services with a specific focus on pediatrics. The MCOs have reviewed the 485, which does not address some of the questions which are on the plan of care for peds. The difference is the 485 is not specific so this form will be required along with the 485.

19. Agency Plan of Care FormInstructions • Instructions: • The form must be submitted with the prior authorization request after the initial assessment has been completed and no later than 30 days from admission or receiving revised orders, and annually. Submit this form as additional clinical information upon completion within the required 30 days. • Orders – The ordering physician must see the enrollee within 30 days of the initial start of care and at least yearly. • Rationale for initial or recertification for PDN/home health service requests with details of the increase, decrease or unchanged hours. Include the medical necessity documentation to support the request for the hours.

20. Instructions cont. • 24 hour Schedule – This schedule will be completed to determine who is responsible for the completion of task for the member’s care for 24 hours. If the schedule changes, this form would need to be filled out and faxed in with the next requests for authorization. If the form isn’t completed on the initiation of services, fax the MCO with the information obtained. The expectation is the form will be completed within 30 days of initiation of services. • Acknowledgment – To be signed on initiation of services, yearly and for members currently receiving services. • Who signs this form? – Physician, Agency, Member/Caregiver • Where do I send the form? The form will be faxed to the member’s MCO.

21. Appendix • Home Health Agency Plan of Care Agreement • Home Health Agency Initial Member/Caregiver Training Checklist • Home Health Agency Recertification Member/Caregiver Training Checklist • Home Health Agency Plan of Care

22. Questions ?