Prior Authorization Requirement
Prior Authorization and Authorization Requirements for PACE (Program of All-inclusive Care for the Elderly), Family Care Partnership, and Family Care Program
To understand what services (Medical and Long-term Care) require authorization, please review the following document:
To be in compliance with Medicare’s Patient Driven Payment Model (PDPM) beginning October 1, 2019, Community Care’s prior authorization practice for post-acute facility Part A Medicare skilled nursing stays is changing for all Medicare beneficiaries enrolled in Community Care’s PACE and Family Care Partnership programs.
Skilled Nursing Facilities (SNFs) will be required to complete Community Care’s “Post-Acute Facility Prior Authorization Request Form” (found in Forms section below) when admitting a PACE or Family Care Partnership member under a Part A Medicare stay.
Completed forms must be sent to Community Care’s Utilization Management department before any authorization will be completed.
Once a Medicare Part A stay is authorized by Community Care, Providers must then complete Community Care’s “Post-Acute Facility Continued Stay Review Form” weekly during the Part A stay providing updates to the progression of the member’s initial plan of care.
Forms (PACE and Partnership Only)
- Post Acute Facility Prior Authorization Request Form
- Post Acute Facility Continued Stay Review Form
- SPECT-PET Imaging Prior Authorization Request Form
- Bariatric and Transplant Surgery Prior Authorization Request Form
- Physician Administered Medications Prior Authorization Request Form
- Hospice Prior Authorization Medicaid Only Form
- Other Medical Services Prior Authorization Request Form
- Genetic Testing and Molecular Pathology Prior Authorization Request Form
