Eligibility, Certification, Face-to-Face Encounter, and Prior Authorization
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).
About this policy
- Policy number
- PA-HH-ADM-03
- Version
- 1.0
- Main rule
- 42 CFR §424.22
- Library
- Pennsylvania home health · 56 policies
- Category
- Service delivery
- Sections
- 18
In short
- 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.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- 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
An inspector may ask
- 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?
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