NY Manual
SHP Manual

SHP Provider Manual
3.2b Sample Service Plan Update Letter (Page 1) | 3.3 Covered and Non-Covered Services

3.2 b Sample Service Plan Update Letter (Page 2)

Authorized Service(s) and/or Item(s):

 

Requesting Provider: <<rp_full_name>>

Requested Date(s) or Service(s): <<re_referral_start_date>>-<<re_referral_end_date>>

Service(s)/Procedure(s)/Units(s): <<re_units_authorized1>>

Service Description: <<re_procedure_code1>>

Authorization Number: <<re_authorization_number>>

 

Requesting Provider: <<rp_full_name>>

Requested Date(s) or Service(s): <<re_referral_start_date>>-<<re_referral_end_date>>

Service(s)/Procedure(s)/Units(s): <<re_units_authorized1>>

Service Description: <<re_procedure_code1>>

Authorization Number: <<re_authorization_number>>   

 
 
 
 
 

 

<<SHP_29 01/2011>>

Home Health Care Determinations

Effective January 1, 2010, subdivision 3 of PHL 4903 was amended to change the timeframe for utilization review determinations of home health care following an inpatient hospital admission. Typically, the request for these home health care services follow an inpatient stay is for skilled services and reimbursable by Medicare.  

If a service is Medicare qualified, it is the provider’s responsibility to determine if the member is Medicare eligible. If the member is Medicare eligible and the service is Medicare qualified, the Provider must bill Medicare and Senior Health Partners will be responsible for the co-pay of covered services. 

Senior Health Partners will furnish utilization review determinations of home health care services following a Medicare denial or exhaustion of a Medicare benefit following an inpatient hospital admission, i.e., in a general hospital that provides inpatient care or inpatient services in an Article 28 rehabilitation facility, as follows: 

     •   Within one business day of receipt of the necessary information OR

     •   Within 72 hours of receipt of the necessary information if the day after the request for services falls on a weekend or holiday 

If a request for home health care services and all necessary information is provided to Senior Health Partners prior to a member’s inpatient hospital discharge, Senior Health Partners will make arrangements to coordinate benefits with the Medicare plan. If no Medicare insurance plan is in place, Senior Health Partners shall not deny the home care coverage request on the basis of a lack of medical necessity or a lack of prior authorization while the determination is pending. 

An appeal of a denial for home health services following a discharge from a hospital admission will be treated as an expedited appeal. 

Reports of Services Rendered

Providers are required to provide written reports to care managers following authorizations for service evaluations and after services provided to members. Payments may be deferred due to delays in receipt of required reports.