Home Health Newsletter January 2025

Dear Valued Clients and Partners,


As the year comes to a close, we at Managed Consultants of America want to express our heartfelt gratitude for your trust and partnership over the past year. Working alongside you to navigate the ever-evolving world of managed care has been a privilege, and we are truly grateful for the opportunity to support your success.

 

Your dedication to providing exceptional care and services inspires us daily, and we’re honored to play a role in helping you achieve your goals. As we look ahead to the new year, we’re excited to continue working together to overcome challenges, seize opportunities, and make an even greater impact.

 

Thank you once again for your confidence in us. We wish you, your team, and those you serve a happy, healthy, and prosperous New Year.


Sincerely,


Destiny Quinones

President/CEO

Managed Care Consultants of America

CMS has published: Updated Part C and D Standardized and Model Notices and the Parts C and D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance effective January 1, 2025. Of significant note for providers of Medicare Advantage plans is the change to the NOMNC for Medicare Advantage (MA) members. Previously on the NOMNC, if the beneficiary or their representative missed the noon before last covered day deadline, they had to appeal directly to the MA plan. Effective January 1st, 2025, the MA beneficiaries or their representatives will submit their untimely appeal directly to the QIO just as those with FFS / Original Medicare would do.

 

There are also changes to the Detailed Notice of Non-Coverage that is produced by the MA plan when a beneficiary has already appealed and had a favorable outcome for continued skilled services. ‘If the enrollee has previously received a favorable BFCC-QIO appeal decision during the current episode of care, detail the specific change(s) in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.’  

 

For complete details, please visit https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-nomnc-denc to download the new NOMNC and DENC for MA plans.

 

FYI – there may not be a MA plan listed on the NOMNC unless the plan issued it directly with their logo on it. So when the beneficiary or representative calls in, the QIO will ask who their payer is i.e. MA plan or Traditional Medicare.

Jimmo v. Sebelius Settlement Agreement Program Manual

CMS has recently updated the previously issued Jimmo v. Sebelius Settlement Agreement Program Manual with clarifications on skilled with improvement vs skilled services with no expectation of improvment and Medicare beneficiaries right to such care.  The updated manual focuses on documentation needed to prove such treatment is necessary.

The premise of the settlement is that skilled services, specifically SNF, Home Health and outpatient therapy, do not require a standard of improvement to meet Medicare guidelines, “…does not turn on the presence or absence of a beneficiaries’ potential for improvement, bur rather on the beneficiary’s need for skilled care”.  “Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition or to prevent or slow further deterioration of the patient’s condition.”   Documentation is upmost importance when considering continuation of services for skilled maintenance services; specifically notating that the skilled services are necessary to prevent or slow further decline and are necessary because of the patient’s particular special medial complications or complexity of the needed services.  The documentation in cases where there is not a clear or defined line of improvement is key in order for reimbursement. 

The CMS link for the notice can be found here Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet (cms.gov) and the CMS settlement agreement with associated files is located here Jimmo Settlement | CMS



Sunshine Health is moving their provider portal to Availity Essentials starting Monday, November 18th, 2024. Providers will be able to verify eligibility, benefits, submit authorization, submit and check claims and more via the Sunshine Health payer resources. This does not change Home Health authorizations managed by a third party, those process will remain the same. 

For additional information Availity Essentials | Sunshine Health

Carelon recently sent out the below notice regarding documentation required; while this is specific to Carelon, it also applies to almost all plans/payers

The Carelon provider portal is the easiest and fastest way to submit for authorization; if your organization does not have a log in to Carelon’s portal, register by clicking here.

Initial Requests: Verbal or signed order, and at least one piece of clinical documentation (H&P, office visit note, discharge summary, etc.)

Reauthorization Requests: Oasis, Plan of Care, clinical documentation (all visit notes, discipline evaluations, wound measurements), and HIPPS code (if available). Once start of care/initial evaluations are completed, all reauthorization requests should have orders that contain the frequency and duration.

Recertifications: verbal or written order, signed Plan of Care, and recert Oasis

ROC’s: Order to ROC and ROC Oasis


Sending in the correct information the first time is key to a smooth and timely process! Carelon | Required Documentation (mailerlite.com)

Paying Attention To The Details!

Housekeeping Items

  • Verify benefits every 1st and 15th of the month as a best practice
  • New employees, please let our liaisons know so we can setup training
  • Discharge Summaries should be sent to the health plans and patient's PCP upon discharge
  • Have you registered for our new portal? Register here!

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