Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Nurses in Independent Practice | 04/20/2024 | Prior Authorization : Plan of CareTopic #1118 A Comprehensive Overview
In accordance with Wis. Admin. Code § DHS 107.12(1)(d), ForwardHealth requires that each member have a written POC. PDN services are required to be provided according to the member's POC, as stated in Wis. Admin. Code § DHS 105.19(2). Topic #1119 Case Sharing Prior Authorization Responsibilities
When two or more PDN providers share a case, it is necessary for the RN who receives the physician's orders to complete Elements 24 and 25 of the PA/CPA.
Each NIP sharing the case is required to obtain a copy of the POC for the effective certification period and countersign and date POC as instructed for Elements 31 and 32 of the PA/CPA. The nurse's countersignature is required to document that they have reviewed the POC and will execute it as written. The countersigned document is a copy of the physician-signed document. The countersigned copy of the POC must be retained with the provider's records.
For each certification period that the countersigning nurse provides services, they are required to countersign and date the POC as instructed for Elements 31 and 32 the PA/CPA before providing services. A nurse may obtain a copy of the POC and countersign and date Elements 31 and 32 of the POC after the certification period "From" date indicated in Element 4; however, the nurse may not submit claims for services provided before the date they countersigned the POC.
When a PAL requests PA but is not the PDN provider designated to receive the physician's orders requests PA, the PAL is required to submit a countersigned and dated copy of the POC with the PA/RF.
The PDN provider designated to receive the physician's orders is not required to keep copies of any POC countersigned by the other nurses. Each provider is required to retain only their own documentation. Topic #1120 Certification Period
Each certification period may last no longer than 62 days. The 62-day period corresponds with the certification period dates in the POC and includes both the "From" date and the "To" date. The POC expires at the end of the 62-day certification period.
ForwardHealth requires that all components of the POC be reviewed and signed by a physician at least every 62 days as stated in Wis. Admin. Code § DHS 105.19(2). If more than one physician orders services, orders are combined on one POC and signed by the primary physician at least every 62 days. The provider obtaining the physician orders on the POC has the responsibility to sign and confirm the date that the information on the POC was reviewed with the physician, to verify that the POC is complete, and to keep a current and complete POC on file. Providers sharing the case must obtain a signed and dated copy of the POC, countersign and date the POC, and retain a copy of the POC.
Once the physician signs the POC, it serves as the physician's orders for the length of the certification period.
The physician must sign and date all subsequent POC prior to the beginning certification date on the POC. Otherwise, the provider is providing services without orders, and such services will not be reimbursed by Wisconsin Medicaid. Topic #2063 Changes to the Plan of Care
When the member's medical needs change, the provider is required to notify the physician so that the physician may order a change to the POC to reflect the member's current medical needs.
It is illegal to add or change orders on a POC after it has been signed by a physician. To add or change orders, providers must have on file a signed and dated copy of the new physician orders to the POC. These changes must be incorporated into the next POC, prior to it being signed by the physician.
ForwardHealth will not accept correction fluid or correction tape on a POC. When correcting errors on a POC before it is signed, a nurse should cross out the error with a single line and place his or her initials and date next to the correction. ForwardHealth will return a POC with other methods of correction to the provider. Topic #1122 Completing the Plan of Care
As required in Element 24 of the PA/CPA Completion Instructions, the RN completing the POC is required to sign the PA/CPA. To complete the POC, the RN is required to do all of the following:
- Develop the nursing POC to include no less information than what is required by the PA/CPA completion instructions.
- Review the information provided in the POC to assure that all required components are included.
- Review the information provided in the POC to assure that it is correct.
Under Wis. Admin. Code ch. N 6.03, an RN is responsible for the POC. Under Wis. Admin. Code ch. N 6.04, an LPN may assist with the development and revision of the POC.
Someone other than the RN may key the required components into the document, but the RN signing the POC takes full responsibility for the contents of the POC. Topic #1123 Developing the Plan of Care
The POC should be based on the orders of a physician, an RN assessment based on a visit to the member's home, and in consultation with the physician, the member or, as appropriate, the member's legal representative, the member's family, and other members of the household.
When developing the POC, the RN should also assess the member's social and physical environment, including the following:
- Family involvement
- Living conditions
- The member's functional status
- Any pertinent cultural factors
LPNs may not develop the POC; however, NIP LPNs are required to read and sign the POC. Wisconsin Medicaid expects each PDN provider on the case to read and sign the POC, regardless of which PDN provider develops the POC. Topic #1145 Documentation Methods
When completing the POC, NIP providing PDN services may use either the PA/CPA, or another format that contains all of the components requested in the completion instructions of the PA/CPA.
Wisconsin Medicaid requires complete and accurate information to adjudicate PA requests submitted for home care services. Incomplete PA requests will be returned to the provider.
Each provider should respond to the PA/CPA Completion Instructions consistent with their provider type and the services being provided under the POC.
Submitting the Prior Authorization/Care Plan Attachment
When completed according to the completion instructions, the POC contains the information Wisconsin Medicaid requires to adjudicate a provider's PA request for home care services.
Submitting Another Format of the Plan of Care
Providers who choose to submit the member's POC in another format are required to include all of the components requested in the PA/CPA Completion Instructions. PA requests received without the requested information will be returned to the provider.
Providers choosing this option should note that the nurse and physician who sign the POC are required to attest to the respective Wisconsin Medicaid certification statements in Section VI of the PA/CPA Completion Instructions.
To speed processing and reduce the number of returned PA requests, providers are strongly encouraged to verify that all requested information is included with the PA request when choosing to submit a POC using a form other than the PA/CPA form. Topic #1124 Element 26 of the Prior Authorization/Care Plan Attachment
If the nurse signing and dating Elements 24 and 25 of the PA/CPA receives verbal orders from the attending physician to start care for the initial certification period, the nurse should enter the date the verbal orders were received in Element 26. If the nurse did not receive verbal orders, Element 26 should be left blank. Topic #1133 Elements 24 and 25 of the Prior Authorization/Care Plan Attachment
Regardless of whether the physician's order is for the start of care with the initial certification period or for continuing care with a recertification period, the RN completing the POC is required to sign and date the POC as instructed for Elements 24 and 25 of the PA/CPA. The RN completing the POC must sign and date the POC on or before the certification period "From" date indicated on the POC. By signing and dating the POC, the RN attests to the following:
- The information contained in the POC is complete and accurate.
- They are familiar with all of the information in the POC.
- When providing services, they are responsible for ensuring that the POC is carried out as specified.
Elements 24 and 25 must be completed on or before the certification period "From" date indicated in Element 4 of the PA/CPA. Topic #10497 Elements 31 and 32 of the Prior Authorization/Care Plan Attachments
Before providing services to the member, each provider on the case must obtain a copy of the PA/CPA for their records and read, sign, and date the PA/CPA in Elements 31 and 32 (Countersignature and Date Signed). The dated signature documents that the nurse has reviewed the POC and will execute it as written. Topic #1136 Indicating Flexible Use of Hours on the Plan of Care
When the flexible use of hours is requested for PDN, providers are required to specify the date(s) that the flexibility period(s) will begin. Enter the flexibility begin dates on the PA/CPA in Element 15 Orders for Services and Treatments. The begin date(s) must be a date (or dates) covered under the POC. Topic #1139 Medical Necessity
The member's health status and medical need, as reflected in the POC, provide the basis for determinations as to whether services provided are reasonable and medically necessary.
Each nurse is responsible, along with the physician, for the contents of the POC relating to the medical necessity of care, accuracy of all information submitted, and relevance of the POC to the member's current medical condition. A nurse is required to do the following:
- Promptly notify the member's physician of any change in the member's condition that suggests a need to modify the POC
- Implement any changes that were made to the POC
Providers are required to include a complete, detailed, and accurate description of the member's medical condition and needs in the POC. The POC should be developed and reviewed concurrently with and in support of other health care providers providing services to the member in the home. Topic #1142 Physician Orders and Signature
All skilled nursing services require a physician's order or prescription. Wisconsin Medicaid will not reimburse for services provided before a physician's order or prescription is obtained. The order or prescription shall be in writing or given verbally and later be reduced to writing by the provider. All orders or prescriptions must be reviewed, signed, and dated by the prescribing physician as stated in Wis. Admin. Code § DHS 107.02(2m).
The initial POC containing the physician's orders must be reviewed, signed, and dated by the physician within 20 working days following the member's start of care. All subsequent POC must be reviewed, signed, and dated by the physician prior to the beginning of the new certification period as specified in Wis. Admin. Code § DHS 107.12(1)(d). Topic #1143 Physician Stamped Signatures
Under specific conditions, Wisconsin Medicaid accepts physicians' stamped signatures on physician orders and POC, including attachments that are submitted with requests for PA.
The home care provider (NIP, Home Health, Personal Care) is required to meet both of the following requirements before accepting a physician's stamped signature:
- Obtain a dated statement from the physician with the physician's original signature attesting that they are the only person who possesses the signature stamp and is the only person who uses it.
- Maintain the signed and dated physician statement in the home care provider's records.
Wisconsin Medicaid will consider a stamped signature invalid if these requirements are not met. Payments made by Wisconsin Medicaid to a home care provider that are based on physician orders, authorized PA requests, or POC stamped with an invalid or improperly used signature stamp will be subject to recoupment. These requirements are similar to those of the federal CMS for providers participating in Medicare.
Signature Stamp Security Awareness for Physicians
Physicians using a signature stamp should be aware that this method is much less secure than a handwritten signature, creating the potential for misuse or abuse of the stamp. The individual whose name is on the signature stamp is responsible for and attests to the authenticity of the information. Physicians should check with their attorneys and malpractice insurers in regard to the use of a signature stamp. Topic #2058 Physician Verbal Orders
At times, the physician may give an order verbally.
Verbal Orders for Initial Certification
Verbal orders may be obtained from the attending physician for the initial certification period; however, the attending physician is required to sign and date the POC within 20 working days of the start of care date. To facilitate immediate access to home care services, Wisconsin Medicaid allows home health and PDN providers to be reimbursed for services provided under verbal orders. The provider is required to reduce the verbal orders to writing, transmit the orders to the physician immediately, and obtain the physician's signature and date on those orders within 20 working days.
Verbal Orders for Subsequent Certification
Once care has started, verbal orders may not be obtained for subsequent certification periods. For ongoing cases, the physician must review, sign, and date renew or (as necessary) revise orders before the end of the certification period for the provider to continue to be reimbursed without interruption after starting care of the member.
The attending physician is required to sign and date the POC prior to the provision of services to the member.
Verbal Orders Within Any Certification Period
An urgent situation may prompt the physician to issue verbal orders. Such verbal orders during the authorized certification period are the direct result of changes in the patient's condition necessitating an immediate modification to the POC. For example, the member's adverse reaction to a currently prescribed medication or treatment may result in a physician verbally ordering a change to the member's treatment or medication.
When verbal orders are necessary within a certification period, the provider must document the orders, reduce them to writing, and sign and date them. The provider has 10 days from the date the physician gave the orders to obtain the physician's signature and date on those orders. Topic #1144 Plan of Care Certification Period Versus Prior Authorization Period
The POC certification period and the PA period refer to two separate time periods.
The requirements for a POC as stated in the PA/CPA Completion Instructions apply to the POC certification period. Regardless of the PA period (which in some cases can be granted for up to a year), the POC must be completed at least every 62 days. Topic #2056 Requirements
The POC must be prescribed by a physician and periodically reviewed by a physician as specified in and supported by all of the following information: Wis. Admin. Code §§ DHS 101.03(124m), DHS 105.16(1), DHS 105.17(2)(b), DHS 105.19(2), DHS 107.02(2m), and
DHS 133.20.
The POC must include all of the following information:
- All pertinent diagnoses, including cognitive status
- Type of services and equipment required
- Frequency of visits
- Prognosis
- Rehabilitation potential
- Functional capabilities and limitations
- Activities permitted
- Nutritional requirements
- Medications and treatments
- Any safety measures to protect against injury
- Instructions for timely discharge or referral
- Other items, as appropriate
- Physician review and signature at least every 62 days or when the member's condition changes, whichever occurs first
Wisconsin Admin. Code § DHS 107.02(2m)(b), requires the prescription or order to include the following information:
- The physician's signature and date
- The physician's name, address, and NPI
- The member's name, address, and member ID
In addition, POC for PDN is required to include the following information:
- Measurable time-specific goals
- Methods for deliverying needed care and an indication of which other professional disciplines, if any, are responsible for delivering the care
- Provisions for care coordination by an RN when more than one nurse is necessary to staff the member's case
- A description of allergies
POC for PDN services to member's ventilator-dependent for life support shall also include the following information as specified in Wis. Admin. Code § DHS 107.113:
- Ventilator settings and parameters
- Procedures to follow in the event of accidental extubation
- Identification of back-ups in the event scheduled personnel are unable to attend the case
- The name of the RN designated as the member's case coordinator
- A plan for medical emergency to include a description of back-up personnel needed; provision for reliable 24-hour a day, seven days a week emergency service for repair and delivery of equipment; and specification of an emergency power source
- A plan to move the member to safety in the event of fire, flood, tornado warning or other severe weather, or any condition which threatens the member's immediate environment
Other Requirements for Plans of Care
Medically necessary cares as ordered by a physician are to include cares that may be claimed by professional providers and cares routinely provided by the family and other volunteer caregivers.
In addition to the elements required on the POC by Wis. Admin. Code § DHS 101.03(124m), agencies should include a brief clinical history and summary of the member's condition to expedite the PA request. This additional information may decrease the frequency of returned PA requests.
For home health therapy services, Wis. Admin. Code § DHS 101.03(124m) also requires the POC to include specific procedures and modalities to be used and the amount, frequency, and duration of the services. Topic #1151 Start of Care
The start of care date is the date of the member's first billable home care visit. This date remains the same on all subsequent POC until the member is discharged from uninterrupted service. Topic #10483 The Same Plan of Care for Private Duty Nursing
The same PDN POC is to be used by all PDN providers sharing the member's case. The POC is developed in consultation with the physician, member, member's family and other providers. All PDN providers shall use the same PDN POC established for the member. The POC must include no less information than is required on the PA/CPA. Each PDN provider sharing the case is required to obtain a copy of the POC for the effective certification period and maintain the POC for their records. |