Home health and private duty nursing services prior authorization process

Reminder of medical necessity reviews, approval time frames and supporting documentation

In response to a request from the Ohio Department of Medicaid, we are reminding you that UnitedHealthcare Community Plan of Ohio assesses each home health and private duty nursing service prior authorization request based on their individual medical necessity to ensure that all members receive the appropriate level of care. This process holds true regardless of network status of the rendering provider. 

Authorization of services

When you submit a prior authorization request for home health or private duty nursing services, the following apply:

• Every authorization request is carefully evaluated to determine medical necessity based on Ohio Administrative Code (OAC) 5160-1-01 and EPSDT guidelines if appropriate, to ensure that members receive the appropriate level of care
• In accordance with OAC Rule 5160-26-03.1, there is no predetermined maximum time frame (e.g., 60 days) for approvals of authorization requests for home health services or private duty nursing

How to submit a request

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

• Go to UHCprovider.com and click Sign In at the top-right corner
• Enter your One Healthcare ID and password
  • New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
• In the menu, select Prior Authorizations
• Scroll down to “Create a new notification or prior authorization request” and click Create New Submissions
• Enter the required information and submit

Supporting documentation matters

Documentation supporting the need for medical necessity is vital for successful authorization requests. This includes:

• Dated plan of care (POC)
  
• Current schedule of nursing hours
• Current treatment administration record 
• 2 weeks of current nursing notes
• Current medication administration records
• Any other applicable documentation

Please note: We are committed to avoiding disruptions in care but recognize that there are occasionally changes in the clinical condition of members, which may lead to alterations in their required care. In such cases, please submit a new authorization and appropriate documentation for any increase or decrease in services in additional to yearly submission with reassessments.

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