Acute Home Health: Intermittent Home Health services provided up to 60 consecutive calendar days
after an acute onset of an illness, injury or disability, hospitalization or acute onset of exacerbations
requiring skilled Home Health care as outlined in the Home Health Benefit Coverage Standard as referenced
in 10 C.C.R 2505-10 § 8.522. Covered Services. Acute Home Health does not require prior
authorization.
PAR Form Instructions
For PAR Revisions:
Complete the Revision section at the top of the form only if revising a current approved PAR.
The number of units should equal more/less the number of units planned for use during the
PAR period. The number of units being requested needs to be added to the original number of
units approved and include all services that were approved on the original PAR. Use one of the
eight (8) lettered (A-H) dropdown fields found in the first few lines immediately following the
last code in Column 9, the “Description” column when a Revision requires:
1) Additional lines of existing codes to indicate varying rates, units, etc.;
2) The inclusion of codes for a timeframe that used codes not listed on the existing form;
3) Change of Provider.
Complete the following required fields:
1. Client Name: Enter the client's name.
2. Client ID: Enter the client's Medical Assistance Program ID number.
3. Birthdate: Enter the client's date of birth.
4.
HCBS Eligible: Check “yes,” if client is currently enrolled in a waiver program. Check “no,” if
client is not currently enrolled in a waiver program or is on the wait-list for a waiver program
(HCPF or DD).
5. Requesting Provider #: Enter the requesting provider's Medical Assistance Program provider
number.
6. Requesting Agency: Enter requesting home health agency.
7. Case Management Agency #: Enter the Case Management Agency number.
8. Dates Covered (From and Through): Enter the PAR start date and PAR end date.
9. Description: List of approved procedure codes.
10. Specify Frequency: Enter visit frequency for home health service requested using daily/weekly,
etc.
11. # Units: Enter the number of units next to the services for which reimbursement is being
requested.
12. Cost Per Unit: Cost per unit automatically populates.
13. Total $ Requested: The total dollar amount requested for the service automatically populates.
14. Total Units Authorized: The Authorizing entity enters the total number of a units approved per
the line.
15.
PAR Determination: This box is completed by the designated review agency. Select the
appropriate determination. Approved (A), Partially Approved (PA), Denied (D)
16.
Comments - Optional: Enter any additional useful information. For PAR revisions this is a
required field and should include if a service is authorized for different dates than in Box 8,
please include the procedure code and date span here.
17. Total Requested Expenditures: Total automatically populates.
18. Number of Days Covered: The number of days covered automatically populates.
