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Face-to-Face Requirements Section 6407 of the Patient Protection and Affordable Care Act of 2010

Date: 07/18/17

Heritage Health (Medicaid):

Attention: Home Health Care (HHC) and Durable Medical Equipment (DME) Providers

This communication is to advise you of the DHHS requirement that effective 7/1/2017 the Heritage Health Plans must comply with the CMS final rule implementing Section 6407 of the Patient Protection and Affordable Care Act of 2010.  The rule adds the requirement of a documented occurrence of a face-to-face encounter with the Medicaid member (which can include telehealth) for the initial order for home health services or durable medical equipment. The primary purpose of the encounter must be related to the services (Home Health Care or Durable Medical Equipment) being prescribed. 

  • HHC:  for the initial order the face-to-face encounter must occur within 90 days before or 30 days after home health services are initiated.
  • DME: for the initial order the face-to-face encounter must occur within six months before or 30 days after the DME order is written. Only DME products requiring prior authorization are subject to this requirement. 
  • Per 42 CFR 440.70, physicians, nurse practitioner and physician assistants may perform the face-to-face encounter, but only physicians may order HHC and DME.

To fulfill our obligations and assure compliance with this requirement, Nebraska Total Care will conduct post payment reviews for initial orders for HHC or DME ordered or initiated on or after July 1, 2017.  Nebraska Total Care will be looking in the HHC or DME servicing provider records for the following documentation:

  • Copy of the order for the services (HHC or DME) signed and dated by the prescribing physician
  • Copy of clinical notes or progress notes that document a face-to-face encounter occurred, the date of the encounter and the purpose of the encounter, e.g. that it relates to the services being prescribed.
  • In addition:
    •  HHC: notes must be dated and signed by a physician, nurse practitioner or physician assistant documenting a face-to-face encounter within 90 days before or 30 days after the date services are initiated.
    • DME: notes must be dated and signed by a physician, nurse practitioner or physician assistant documenting a face-to-face encounter within six months before or 30 days after the DME order is written.

If there is no evidence that a face to face encounter occurred that meets the above requirements, Nebraska Total Care will initiate a recoupment for payments made for those services, consistent with DHHS expectations.

The provider may, at their own discretion, submit the documentation in advance when a prior-authorization is requested; however, this is not required. Pleae see the Heritage Health Health Plan Advisory No. 17-02 (PDF) related to the Face-to-Face encounter requirement.