Home Health Care Authorization Bundles
To ensure patients receive coordinated care and remove administrative burden for providers, we have the following home health care bundles to better streamline prior authorization. Each bundle is a group of commonly requested visit types and number of visits based on diagnosis.
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| Generic diagnosis | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| N/A | Skilled nursing (G0299, G0300) | 3 visits | 2 visits | |
| Physical therapy (G0151, G0157, G0159) | 3 visits | 3 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 1 visit | 1 visit | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 3 visits | 3 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Orthopedic | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| Applies to knee and hip replacement post care and spinal surgery post care | Skilled nursing (G0299, G0300) | 6 visits | 3 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 8 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 4 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 6 visits | 3 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Heart failure | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| I50–I50.9 | Skilled nursing (G0299, G0300) | 12 visits | 8 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 8 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 12 visits | 6 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Heart disease (myocardial infarction, coronary artery disease, coronary artery bypass graft) | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| I21.0–I21.9 | Skilled nursing (G0299, G0300) | 12 visits | 6 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 6 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 4 visits | 2 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 3 visits | 2 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Chronic obstructive pulmonary | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| J44.0–J44.9 | Skilled nursing (G0299, G0300) | 12 visits | 8 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 8 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 12 visits | 6 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Cerebrovascular accident and transient ischemic attack | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| I63.0–163.9 | Skilled nursing (G0299, G0300) | 12 visits | 8 visits | |
| Physical therapy (G0151, G0157, G0159) | 16 visits | 12 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 6 visits | ||
| Speech therapy (G0153) | 8 visits | 4 visits | ||
| Home health aide (G0156) | 12 visits | 8 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Pneumonia | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| I21.0–I21.9 | Skilled nursing (G0299, G0300) | 12 visits | 6 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 6 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 4 visits | 2 visits | ||
| Speech therapy (G0153) | 1 day | 1 visit | ||
| Home health aide (G0156) | 8 visits | 4 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Open wound | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| S00–S99 | Skilled nursing (G0299, G0300) | 20 visits | 10 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 8 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 3 visits | 2 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Diabetes mellitus | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| E08.2–E13.29 | Skilled nursing (G0299, G0300) | 16 visits | 8 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 6 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 3 visits | 1 visit | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Hypertension | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| I10–I17 | Skilled nursing (G0299, G0300) | 16 visits | 8 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 6 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 3 visits | 1 visit | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Chronic kidney disease and end stage renal disease | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| N18.1–N19.9 | Skilled nursing (G0299, G0300) | 16 visits | 10 visits | |
| Physical therapy (G0151, G0157, G0159) | 12 visits | 8 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 4 visits | 2 visits | ||
| Speech therapy (G0153) | 1 day | 1 day | ||
| Home health aide (G0156) | 3 visits | 3 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||
| Oncology | Visits Allowed | |||
|---|---|---|---|---|
| Diagnosis codes | Visit type | Initial 60-day request | Second 60-day request | |
| C00–C96 | Skilled nursing (G0299, G0300) | 16 visits | 12 visits | |
| Physical therapy (G0151, G0157, G0159) | 16 visits | 12 visits | ||
| Occupational therapy (G0152, G0158, G0160) | 8 visits | 4 visits | ||
| Speech therapy (G0153) | 1 visit | 1 visit | ||
| Home health aide (G0156) | 12 visits | 8 visits | ||
| Social worker (G0155) | 1 visit | 1 visit | ||