Home health

All home health visits for members require prior authorization. To request authorization use our Auth Request tool.

Medicare coverage education for providers

If you provide skilled home care services and/or skilled physical, occupational and speech therapy to Medicare beneficiaries, then you're required to understand the issues of the Jimmo v Sebelius case and the resulting Jimmo Settlement Agreement on coverage.

Learn more on our Jimmo Settlement Agreement page.

Standard contracted services

All contracts include home health care. The Jimmo v Sebelius Settlement clarified CMS rules for skilled care and related documentation. See our Jimmo v Sebelius page for details and requirements for home health education.

Retrospective authorizations

If you provide a service that requires prior authorization to an MA/MAPD plan member without first getting authorization, you can't send us an authorization request after the fact. You must submit a Request for payment. See Retrospective authorizations for details.

Appealing coverage for non-covered skilled care

Should the MA/MAPD plan member appeal the termination decision, Livanta, the Quality Improvement Organization (QIO) for the state of Michigan, notifies Priority Health of the member's appeal. Priority Health - not the home health care services - must then issue a CMS-10124 form, Detailed Explanation of Non-coverage (DENC).

No later than the close of business the day that it is notified of the member appeal, Priority Health must:

  1. Complete a CMS-10124 form, Detailed Explanation of Non-coverage (DENC), with specific and detailed information about why home health services are ending.
  2. Upload a copy of the form to the Michigan QIO, Livanta. 
  3. Issue the DENC form to the plan member.

The DENC serves to inform the member of the reason for the coverage termination so he/she has an opportunity to present his/her views to the QIO.

Home health care agencies may not appeal on behalf of a member unless the home health care agency is member's appointed representative; proof may be required by the QIO.

Required appeal information for providers: 

Be sure to have designated weekend and evening staff responsible for completing required tasks for Livanta.

Priority Health staff can assist you with questions for after-hours or weekend appeals. Call our on-call nurse at 800.259.1260.

The following information must be uploaded to Livanta:

  • History and physical
  • Physician orders
  • Physician progress notes
  • PT evaluation and progress notes
  • OT evaluation and progress notes
  • ST evaluation and progress notes
  • Social service/DC planning notes
  • Skilled nursing notes
  • Wound care orders and flowsheets
  • Face sheet

Livanta due dates and times:

  • During regular business week/hours: 5:00 p.m. on same day
  • After business hours: Noon the next day
  • Weekends: 3:00 p.m. Monday

Find more information on Medicare in-home safety assessments and post acute care