256B.0652 PRIOR AUTHORIZATION AND REVIEW OF HOME CARE SERVICES.
Subdivision 1. State coordination.
The commissioner shall supervise the coordination of the
prior authorization and review of home care services that are reimbursed by medical assistance.
Subd. 2. Duties.
(a) The commissioner may contract with or employ qualified registered
nurses and necessary support staff, or contract with qualified agencies, to provide home care
prior authorization and review services for medical assistance recipients who are receiving
home care services.
(b) Reimbursement for the prior authorization function shall be made through the medical
assistance administrative authority. The state shall pay the nonfederal share. The functions will
(1) assess the recipient's individual need for services required to be cared for safely in
(2) ensure that a service plan that meets the recipient's needs is developed by the appropriate
agency or individual;
(3) ensure cost-effectiveness of medical assistance home care services;
(4) recommend the approval or denial of the use of medical assistance funds to pay for
home care services;
(5) reassess the recipient's need for and level of home care services at a frequency determined
by the commissioner; and
(6) conduct on-site assessments when determined necessary by the commissioner and
recommend changes to care plans that will provide more efficient and appropriate home care.
(c) In addition, the commissioner or the commissioner's designee may:
(1) review service plans and reimbursement data for utilization of services that exceed
community-based standards for home care, inappropriate home care services, medical necessity,
home care services that do not meet quality of care standards, or unauthorized services and make
appropriate referrals within the department or to other appropriate entities based on the findings;
(2) assist the recipient in obtaining services necessary to allow the recipient to remain safely
in or return to the community;
(3) coordinate home care services with other medical assistance services under section
(4) assist the recipient with problems related to the provision of home care services;
(5) assure the quality of home care services; and
(6) assure that all liable third-party payers including Medicare have been used prior to
medical assistance for home care services, including but not limited to, home health agency,
elected hospice benefit, waivered services, alternative care program services, and personal care
(d) For the purposes of this section, "home care services" means medical assistance services
defined under section
256B.0625, subdivisions 6a, 7, and 19a
Subd. 3. Assessment and prior authorization process.
Effective January 1, 1996, for
purposes of providing informed choice, coordinating of local planning decisions, and streamlining
administrative requirements, the assessment and prior authorization process for persons
receiving both home care and home and community-based waivered services for persons with
developmental disabilities shall meet the requirements of sections
with the following exceptions:
(a) Upon request for home care services and subsequent assessment by the public health
nurse under sections
, the public health nurse shall
participate in the screening process, as appropriate, and, if home care services are determined to
be necessary, participate in the development of a service plan coordinating the need for home care
and home and community-based waivered services with the assigned county case manager, the
recipient of services, and the recipient's legal representative, if any.
(b) The public health nurse shall give prior authorization for home care services to the
extent that home care services are:
(1) medically necessary;
(2) chosen by the recipient and their legal representative, if any, from the array of home care
and home and community-based waivered services available;
(3) coordinated with other services to be received by the recipient as described in the service
(4) provided within the county's reimbursement limits for home care and home and
community-based waivered services for persons with developmental disabilities.
(c) If the public health agency is or may be the provider of home care services to the
recipient, the public health agency shall provide the commissioner of human services with a
written plan that specifies how the assessment and prior authorization process will be held
separate and distinct from the provision of services.
History: 1991 c 292 art 7 s 13; 1Sp1993 c 1 art 5 s 54; 1995 c 207 art 3 s 18; art 6 s 56;
1996 c 451 art 2 s 21; 2005 c 56 s 1