{"ref":"FL-HH-ADM-03","title":"Medicare and Medicaid Eligibility, Certification, Face-to-Face Encounter, and Authorization","category":"Service delivery","summary":"Sets how the Agency verifies coverage before care and makes sure every Medicare and Florida Medicaid patient meets the conditions for payment: the Medicare eligibility requirements (confined to the home, under the care of a physician or allowed practitioner, need for intermittent skilled nursing or therapy, under a plan of care), the certification and recertification by the physician or allowed practitioner, the face-to-face encounter within the 90 days before or the 30 days after the start of care (Medicare and Medicaid), documentation that supports eligibility, practitioner financial relationships, Florida Medicaid and managed care authorization, and signed orders before a claim is submitted.","inShort":["Check every patient's insurance and get any required authorization before the first visit.","For Medicare, write down why the patient is confined to the home at every assessment.","The practitioner must document a face-to-face visit with the patient within 90 days before or 30 days after care starts.","Treatment orders must be signed before we bill for the care.","If coverage ends or is denied, tell the case manager so the patient and practitioner can be told quickly."],"primaryCitation":"42 CFR §424.22","citations":["s. 400.487(2), F.S.","s. 400.5185, F.S.","Rule 59G-4.130, F.A.C.","s. 409.913(7), F.S.","s. 409.913(9), F.S."],"federalCitations":["42 CFR §424.22","42 CFR §424.22(a)","42 CFR §424.22(b)","42 CFR §424.22(c)","42 CFR §424.22(d)","42 CFR §409.42","42 CFR §409.43","42 CFR §440.70(f)","42 CFR §484.55","42 CFR §405.1200"],"surveyorAsks":["Show me the certification for this Medicare patient. Where is the face-to-face encounter documented, and when did it occur?","Where does this record support that the patient is confined to the home?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §424.22)","5. Verifying Coverage Before the First Visit","6. Medicare Eligibility","7. Certification by the Physician or Allowed Practitioner","8. The Face-to-Face Encounter","9. Recertification","10. Documentation That Supports Eligibility","11. Practitioner Financial Relationships","12. Florida Medicaid, Managed Care, and Other Payers","12.1 Florida Medicaid","12.2 Medicare Advantage and private insurance","13. Signed Orders Before Billing","14. When Eligibility or Authorization Is Not Met","15. Responsibilities","16. Records and Compliance Monitoring","17. Staff Training","18. References","19. Related Policies and Forms","20. Approval","21. Revision History"],"version":"1.0","sample":false,"pack":"fl-hha","state":"Florida","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}