Idaho Medicaid Provider Handbook, Home Health and Hospice Services § 3.5

If the participant is 21 years of age or older or requires skilled nursing or home health aide

visits over the 100-visit limit, the agency must upload documentation to the Telligen, Inc.

Qualitrac portal for prior authorization. Approval will be determined on a case-by-case basis.

The following documentation is required to determine the need for additional visits:

•

Completed Home Health Prior Authorization Request Form;

•

Current physician’s order;

•

Current signed Home Health Certification and Plan of Care;

•

Last 30 days’ visit notes;

•

Current history and physical;

•

Hospital discharge/admission orders and paperwork; and

•

Any other documentation that will support medical necessity or is needed for manually

priced items.

If the participant is under 21 years of age or requires occupational or physical therapy, or

speech language pathology visits over the 100-visit limit, the agency must upload

documentation to the Telligen, Inc. Qualitrac portal for prior authorization. Approval will be

determined on a case-by-case basis. If the participant is discharged or terminates services

after the prior authorization is approved, the agency must timely inform Telligen, Inc. by

phone or e-mail the last service date. The following documentation is required to determine

the need for additional visits:

•

Completed Home Health Prior Authorization Request Form;

•

Current physician’s order starting from date of 100th visit through December 31st;

•

Current signed Home Health Certification and Plan of Care;

•

Last 30 days’ visit notes;

Any other documentation that will support medical necessity.

Telligen, Inc. only accepts prior authorization requests, medical record updates for post

payment medical necessity, and All Patient Refined (APR) Diagnosis Related Group (DRG)

validation reviews through its online Qualitrac portal. For specific instructions on how to

submit these requests, see Telligen’s Provider Manual at Idmedicaid.telligen.com. See the

General Billing Instructions, Idaho Medicaid Provider Handbook for additional information on

billing and requesting prior authorized services and manually priced items.