Authorization Documentation Tips
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. This page provides guidance on proper documentation for successful Prior Authorization submission. By submitting proper documentation with your prior authorization (PA) requests, PAs can be reviewed more expeditiously leading to efficient turnaround times for reviews and notifications. This supports getting members connected to needed services promptly.
Review all clinical policies online for complete guidance and coverage criteria.
Outpatient Specialized Therapies Clinical Coverage Policy No: 10A
Required Documentation:
- Signed MD Order within the last 6 months
- Evaluation/progress notes from the past 3 months Plan
of Care - For continuations: new order (if previous is signed & dated longer than 6 months ago) and an updated plan of care stating frequency and duration of therapy.
Required Documentation:
- HH Therapy: Physician Order/Signed Plan of Care (CMS-485 form), Face to face encounter within 90 days prior or within 30 days after starting care, Therapy Evaluation and Plan of Care. Therapy evaluation must be completed prior and submitted with the Prior Authorization request.
- HH Skilled Nursing: Physician Order/Signed Plan of Care (CMS-485 form), Face to face encounter within 90 days prior or within 30 days after starting care.
Physical Rehabilitation Equipment and Supplies, 5A-1
Respiratory Equipment and Supplies, 5A-2
Nursing Equipment and Supplies, 5A-3
Orthotics and Prosthetics, 5B
Reminders:
- A PA is required for anything over the benefit limit outlined in the Clinical Coverage Policy.
- Carolina Complete Health is committed to supporting postpartum breastfeeding mothers by covering breast pumps, regardless of specific medical necessity criteria outlined in policy 5A-3. No prior authorization is required, and claims should be submitted through the usual process.
Providers do not need to request authorizations or re-authorizations for Personal Care Services. For guidance on initial PCS request and re-assessments, see our Personal Care Services and Home Health provider resource page.