{"ref":"PA-HH-ADM-03","title":"Eligibility, Certification, Face-to-Face Encounter, and Prior Authorization","category":"Service delivery","summary":"Sets out how the Agency confirms, before and during care, that each patient meets the conditions of their payer: for Medicare, the homebound, skilled need, plan of care and physician or allowed practitioner requirements, the face-to-face encounter, certification and recertification; for Medical Assistance, the attending physician’s certifications, the 60-day review, and prior authorization; and for licensure, the attending physician’s supervision under 28 Pa. Code §601.31(a).","inShort":["For Medicare, check and record at each assessment why the patient is homebound and what skilled care they need.","Ask for the face-to-face encounter note at referral; it must be dated within 90 days before or 30 days after the start of care.","Medical Assistance services need the physician’s certifications and, where required, prior authorization before the visits.","Plans of treatment must be signed and dated by the physician before the claim is sent.","Never change or backdate a record to make a patient look eligible; report any concern."],"primaryCitation":"42 CFR §424.22","citations":["55 Pa. Code §1249.41","55 Pa. Code §1249.52(a)","55 Pa. Code §1249.42(2)","28 Pa. Code §601.31(a)"],"federalCitations":["42 CFR §424.22","42 CFR §409.42","42 CFR §409.43","42 CFR §484.55","42 CFR §484.2"],"surveyorAsks":["How do you verify that a Medicare patient is homebound? When?","Show me the face-to-face encounter documentation for this patient. Who performed it, and when?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §424.22)","5. Medicare Eligibility","6. Face-to-Face Encounter","7. Certification and Recertification","8. Medical Assistance Recipients","9. Other Payers","10. When Eligibility Is in Doubt","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"pa-hha","state":"Pennsylvania","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}}