The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities for
home health care services to Tango (a post acute management services and home health network company). Tango's internal coverage criteria are based on applicable statutes, regulations, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual and other applicable Medicare coverage documents.
Home health care services that do not meet Medicare's qualifying skilled service requirements are considered not medically necessary and, therefore, not covered.
Refer to the Reference section of this policy for a link to Medicare Benefit Policy Manual, Chapter 7 – Home Health Services.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
