Private Duty Nursing and Pediatric Long-Term Home Health Services Pre-Approval Project

The Department of Health Care Policy & Financing previously notified Pediatric Long-Term Home Health (PLTHH) and Private Duty Nursing Providers that the Prior Authorization Request (PAR) requirement for these services would be suspended as of July 1, 2020. After considerable evaluation, stakeholder engagement, and internal discussion, the Department has determined to keep the PAR requirement suspended through winter 2020/2021 and will resume the submission of PLTHH and PDN PARs to the UM Vendor no earlier than March 1, 2021. Upon restarting the PARs for these benefits, the Department will provide timely communication to members, Providers and other stakeholders to allow for planning and preparation purposes. The resumption of the PAR requirement for these services will involve a phased-in implementation and the Department will collaborate with Providers to develop the plan for each phase of PAR submissions.

As previously communicated, Providers can, and should, continue to provide medically necessary services in compliance with Department rules at 10 CCR 2505-10, Sections 8.520 and 8.540. If the services are medically necessary and in compliance with rules and regulations, Providers can submit the claims to the Department's fiscal agent, Gainwell Technologies.

Additional information about the future resumption of PLTHH and PDN PARs will be shared with Providers via Gainwell Technologies, posted on the Department's Project website, and on the ColoradoPAR program website. If there are additional questions, concerns or specific issues regarding these PARs please email the Department's UM Team at hcpf_UM@state.co.us and email questions regarding policy to the Department's Benefits team at hcpf_benefitsupport@state.co.us.

Please Note: This PAR suspension does not affect Long Term Home Health PARs for Adults (members aged 21 and over) and for any issues regarding Adult Long Term Home Health, Providers should contact the appropriate Case Management Agency or hcpf_lthhPARs@state.co.us.

For Members

Action Needed: None Currently
If you currently have private duty nursing services, pediatric long-term home health services, or both, you will receive a letter with more information.

For Providers

Action Needed: Providers need to ensure their User Administrator is set up with eQSuite, so they receive timely communication regarding PDN/PLTHH PAR submission in progress when those updates start coming out. If you currently treat members who receive private duty nursing services, pediatric long-term home health services, or both, you will need to submit an updated plan of care and supporting documentation in the new request. 

Trainings

Frequently Asked Questions

Documentation

For clinical documentation to support requests, would this come only from the Home Health agency or is it a combination of home health assessment and referring provider documentation?
Documentation to support the request can come from the member's home health agency, primary care physician, other specialists providing care relevant o the request or any other recent clinical documentation. This documentation would be provided to the Home Health Agency and then submitted with the PAR via the online PAR portal. For supporting clinical documentation that would help support the need for the requested services are welcome. Please refer to the billing manual for specifics on documentation requirements but at a minimum supporting documentation should include the Pediatric Assessment Tool, recent physicians' notes, appropriate prescriptions and doctor's orders, recent nurse's visit notes, etc. The UM Vendor may request additional documentation necessary not specifically stated above or in the Billing Manual to support this request.

Appeals

If a member appeals a denial, is it the members responsibility to attach additional provider documentation or will UM reach out to the provider for more information?
If an appeal has been filed, and there are questions regarding the appeal process, the Department's Appeals team will be able to provide an answer. Please reach out to hcpf_memberbenefitappeals@state.co.us.

What is the time frame for appeal?
Members have 60 calendar days from the date of the PAR notice to file an appeal. Additionally, the member's appeal rights included in the determination letter will provide detailed information about the member's appeal rights including next steps and due date to file an appeal.

During the appeal, for continuation of benefits are those billable units provided and paid for by Medicaid? Are the requested units available in the denied or partially approved par numbers?
Continuation of benefits does mean that the services are billable during that period. When the PAR requirement is in place, if a member receives a continuation of benefits, the PAR will be authorized with the appropriate codes and units for the period of the appeal.

Would the member need to file both an appeal and continuation of benefits?
No, when a member files an appeal for a PAR determination, and they were previously receiving the benefit continuously, continuation of benefits will be authorized on the PAR. If a member was not receiving PDN or pediatric LTHH previously or there was a break between last authorization and current PAR, continuation of benefits will not be issued.

EPSDT

Is there a reason why PDN hours are stepped down to 16 when a member turns 21? Is that what is allowed for an adult?
Yes, a member who is 21 does not have access to the EPSDT program and benefits can have hard limits on services. The limit for these services is 16 hours per day. If the member was previously receiving PDN services at 24 hours a day, and turns 21, services will be stepped down to the appropriate level over a 3-month period.

If the member's needs do not change when they turn 21 and they still need the 24 hour oversight, are there additional options for assistance?
Please refer to the waiver training for an in-depth discussion on available options.

Waivers

Do the hours approved for PDN impact what other services they can receive? I spoke with an agency yesterday and they mentioned a "CAP" that hours would be split between day care and PDN.
Hours that are split between services in this manner are hours in a member's care plan for one of the child or adult waivers. Please refer these questions to the CMA.

Pediatric Personal Care Benefit

A member was recently denied for the Pediatric Personal Care Benefit due to having the CNA hours. The hours were not overlapping, so curious as to why a denial would be given?
Members authorized for multiple services/benefits, such as Personal care, Pediatric Long Term Home Health, and Private Duty Nursing will be reviewed for duplication, and any services that are duplicative will not be authorized. For any questions or issues regarding PARs for specific members or authorizations please reach out to HCPF_UM@state.co.us with specifics including the member ID, review ID or PAR number, summary of the issue.

Regional Accountable Entities (RAEs)

It seems much of this applies to the process for the ordering providers and home health agencies. What roles do you see RAE Coordinators assisting with?
The Department expects the RAEs to ensure that care coordination and appropriate services are available to members. The RAEs do not necessarily have to take the lead if care coordination and services are already being provided through a case manager or home health agency, the RAEs need to ensure appropriate services and care coordination are available and report this information in a format and frequency agreed upon by the Department.

In the last scenario, you mentioned that the parents were requesting more hours than were determined medically necessary. You mentioned this case would then be sent to the RAE - what would you expect from the RAE at that point?
We would expect the RAE to work with the family to understand available options and to communicate with the family what those options are. RAEs may consider looking for options outside their region, level-setting with the family and provider about the availability and service delivery of different options, or potentially look into other service delivery models (waivers) as appropriate.

Will the information being provided be sent out in writing to the RAEs regarding the process (i.e. 60-day continuation of services with denial or reduction, process for when someone turns 21 for PDN or CNA services)?
All trainings and relevant documentation will be posted on the Private Duty Nursing and Pediatric Long-Term Home Health Services Pre-Approval Project web page. Providers can also utilize the ColoradoPAR website to view additional provider resources including training, guides, etc.

When you speak of the UM provider, are they reaching out to the submitting provider (home health agency) or to the physician (or both)?
When submitting a reconsideration request, either the ordering or treating provider (physician or home health agency) can submit the request. When submitting a peer to peer request, the UM provider can only be the ordering or treating physician.

How can the RAE best explain to members and home health agencies/providers around why PDN denials are occurring now when they didn't previously?
Nothing has changed with the program as the Department is following the posted rules and regulations. These services have required a prior authorization for more than 5 years. The PAR requirement was suspended only as of July 1, 2020, so upon re-starting the PARs will return to using the same requirements.

When the RAE receives the list of denials, do the members and/or home health know about the denial yet?
Yes, the members should have already been notified by letter and most likely by the requesting provider as well.

Utilization Management

The UM vendors have previously been asking for a clients IEP (individualized education program). However, home healthcare is not provided while the client is in school and this can be difficult to obtain. Why would this be necessary and is it appropriate for the UM vendor to make this type of request?
The vendor should no longer be requesting only the IEP and if they are please notify HCPF.UM@state.co.us with members and review specific information. However, there are instances where the UM Vendor will request documentation to support the request and will provide examples of documentation that may contain the information, which may include the IEP. Additionally, if an appeal is filed, the IEP may be requested of the member, if available, by the Department's appeals team.

If a PDN or CNA PAR is denied, is a denial sent to the ordering physician with information on how they might request a peer to peer review, including the UM vendor's phone number?
The ordering Provider will receive a copy of the Provider's determination letter upon resuming the PAR process for PLTHH and PDN. The Home Health Agency Provider will be able to view the denial in the online PAR portal.

If the provider misses the 10 day deadline, would they then have to resubmit a new request for services?
If the Home Health Agency receives a request for additional information via a pend, and does not respond within the 10 days, the PAR will be technically denied for Lack of Information. The Provider that made the referral for home health may then request a reconsideration for technical and medical necessity denials within 10 Business Days. Please refer to the reconsideration guide for additional information. Please note: A Home Health Agency cannot request a reconsideration.

If the PAR has been denied, and is outside of the 10 business day timeframe, a Provider may re-submit the PAR with all necessary documentation. However, any re-submitted PARs could not be backdated past the established timeliness requirements. The best way for Home Health Agencies to avoid unnecessary technical denials for lack of information is to ensure that they are submitting all necessary documentation and reviewing requests for additional information and responding timely. To ensure that providers are getting the notifications about requests for additional information, they should review the eQSuite User Guide and ensure that they are receiving all notifications via email.

Wanted to clarify the timeline - Is this understanding correct: eQHealth has 4 days to make a decision after the provider has 10 days to submit documents, then another 10 days after the decision to request a reconsideration - so the whole PAR process can potentially be 24 days?
Once the Provider initially submits the PAR eQHealth has 4 Business Days to review the PAR and determine if it should be approved, or additional information is necessary. If eQHealth requests additional information, the Provider has 10 Business Days to respond to the request, and once all necessary documentation is submitted to eQHealth they have no more than 4 Business Days to approve or deny the request. eQHealth can pend the PAR back to the provider 2 times if the documentation is not submitted in the initial request. Once a decision is made by eQ, then the provider has 10 business days to submit a request for reconsideration.

How else will they know that they have that P2P opportunity?
The Ordering Provider can request a Peer to Peer (P2P) on a medical necessity denial letter (partial or full) only. Providers can view additional information about the P2P here. Oftentimes, upon notification of a medical necessity denial, the home health agency will reach out to the ordering physician and collaborate to request a P2P if appropriate.

Is the P2P 10 business days or 10 calendar days?
10 calendar days, 10 business days for a reconsideration request.

If the physician or provider needs more time to gather info, can they request an extension of time?
Due to Colorado rules and regulations as well as contract requirements, the period of time for Providers to respond to a request for additional information cannot be extended past the 10 day response timeframe. In order to avoid the need for additional time to respond to a request for additional information is to ensure that all supporting and required documentation is submitted appropriately initially.

So the upfront timeline while the provider is submitting documents is ambiguous?
The Department cannot regulate the individual provider business processes. However, the best way for Home Health Agencies to avoid delaying a PAR determination is to ensure they are submitting all necessary documentation and reviewing requests for additional information and responding timely. To ensure that providers are getting the notifications about requests for additional information, they should review the eQSuite User Guide and ensure that they are receiving all notifications via email.

Who do we email with questions?
For questions or concerns regarding prior authorizations and/or the UM Vendor, please email HCPF.UM@state.co.us. If you have questions regarding the benefit and/or policy please contact hcpf_benefitsupport@state.co.us
.

Toolkit