[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283869-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283869-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","home-health-care-re-authorization-form-request-submission","Home Health Care Re-authorization Form - Request Submission","","Home Health Care Re-authorization Form is designed for submitting re-authorization requests with required member, agency, diagnosis, and authorization details. The form supports standard, retro, and urgent request types and includes authorization numbers and start-of-care dates. It captures physician and following/plan-of-care information, agency request certification and 30-day review selection, and discipline-specific visit request data. A required checklist outlines supporting orders and signed clinical documents for timely review processing, along with confidentiality guidance.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/home-health-care-re-authorization-form-request-submission/283869/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/home-health-care-re-authorization-form-request-submission/283869.png","ImageObject",442,249,{"name":42,"@type":43},"Cipher","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should the Home Health Care re-authorization form be sent, and how is it submitted?","Question",{"text":63,"@type":64},"Fax the completed form along with the required information to 844-834-2908. Questions can be directed by calling 844-411-9622.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is required to process the re-authorization request?",{"text":68,"@type":64},"The form collects member details (including name, DOB, state of residence, member ID, and plan IDs), residence type, primary/secondary/tertiary diagnosis codes, HIPPS code, and authorization information. It also requests physician details, agency information, and certification period and review selection.",{"name":70,"@type":61,"acceptedAnswer":71},"What supporting documents are required according to the checklist?",{"text":72,"@type":64},"Provide a verbal or signed order with frequency and duration (when needed), a completed signed SOC OASIS for the first reauthorization request, and updated clinical documentation including ROC OASIS and signed 485/POC for services requested, plus visit notes and wound measurements if applicable.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283869,1790210657,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","FOR FASTER AUTHORIZATIONS, PLEASE VISIT:  \n[https://providers.carelonmedicalbenefitsmanagement.com/postacute/](https://providers.carelonmedicalbenefitsmanagement.com/postacute/)  \nHOME HEALTH CARE RE-AUTHORIZATION FORM  \nPLEASE FAX THIS FORM ALONG WITH THE REQUIRED INFORMATION TO: 844-834-2908 Questions? Call 844-411-9622  \n\n| Date of Request: | Standard Request: Retro Request: Urgent Request: |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Note: Expedited organization determinations (urgent requests) can only be requested by the Member, Member Representative, or a Physician and only if applying the standard timeframe could seriously jeopardize the life or health of the member. (See CMS regulation: 40 .8) |  |  |  |  |  |  |\n| All Information Required to Process Request in a Timely Manner |  |  |  |  |  |  |\n| Member Information\u003Cbr>Name:\u003Cbr>DOB:\u003Cbr>State of Residence:\u003Cbr>Member ID \\#:\u003Cbr>Health/Benefit Plan ID:\u003Cbr>Able/Willing/Teachable Caregiver: Yes\u003Cbr>If no, please explain: |  |  | No | Agency Information\u003Cbr>Agency:\u003Cbr>Name:\u003Cbr>Email:\u003Cbr>NPI:\u003Cbr>Phone:\u003Cbr>Fax: |  |  |\n| Residence Information\u003Cbr>Private Residence:\u003Cbr>Assisted Living:\u003Cbr>Independent Living:\u003Cbr>Long Term Care:\u003Cbr>Other: |  |  |  | Diagnosis Information\u003Cbr>Primary Diagnosis & Code:\u003Cbr>Secondary Diagnosis & Code:\u003Cbr>Tertiary Diagnosis & Code:\u003Cbr>Quaternary Diagnosis & Code:\u003Cbr>HIPPS Code: |  |  |\n| Authorization Information\u003Cbr>Auth Number:\u003Cbr>Start of Care Date: |  |  |  | Physician Information\u003Cbr>Following/Plan of Care/NP:\u003Cbr>NPI:\u003Cbr>Phone:\u003Cbr>Fax: |  |  |\n| Agency Request\u003Cbr>Certification Period: From To 30-Day Review Period (make selection): A or B |  |  |  |  |  |  |\n| Discipline |  | Date of Last Visit |  |  | Number of Visits Requested | Plan of Care Frequency |\n| Skilled Nursing |  |  |  |  |  |  |\n| Physical Therapy |  |  |  |  |  |  |\n| Occupational Therapy |  |  |  |  |  |  |\n| Speech Therapy |  |  |  |  |  |  |\n| Home Health Aide |  |  |  |  |  |  |\n| Medical Social Work |  |  |  |  |  |  |\n| Required Checklist: The items below are required for the review process. Please submit this completed form along with the listed requirements.\u003Cbr>1. Verbal or signed order (including frequency and duration to cover requested visits) if a new skill is being requested OR if not submitted with initial request.\u003Cbr>2. Completed signed SOC OASIS for first reauthorization request.\u003Cbr>3. Updated clinical documentation (completed ROC OASIS, signed 485/POC) for all services being requested. Along with all visit notes, ensure the evaluation is being or has been submitted.\u003Cbr>4. Provide wound measurements from previous visits- if applicable for wound care. |  |  |  |  |  |  |\n| CMS Definition: Homebound status certified by MD; there is a normal inability to leave home and leaving the home is a considerable and taxing effort. |  |  |  |  |  |  |\n| CONFIDENTIALITY NOTICE: This fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or may otherwise be protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by fax and destroy all copies of the original message and any attachment thereto. |  |  |  |  |  |  |\n\n[carelon.com](carelon.com)  \n© 2025 Carelon Medical Benefits Management","cbCaikx8sT5spti6","https://ap.wps.com/l/cbCaikx8sT5spti6","pdf",297809,"English","# Request Details\n## Member Information\n## Residence and Diagnosis Information\n## Authorization and Physician Information\n## Agency Request and Visit Details\n## Required Checklist\n## Confidentiality Notice","[{\"question\":\"Where should the Home Health Care re-authorization form be sent, and how is it submitted?\",\"answer\":\"Fax the completed form along with the required information to 844-834-2908. Questions can be directed by calling 844-411-9622.\"},{\"question\":\"What information is required to process the re-authorization request?\",\"answer\":\"The form collects member details (including name, DOB, state of residence, member ID, and plan IDs), residence type, primary/secondary/tertiary diagnosis codes, HIPPS code, and authorization information. It also requests physician details, agency information, and certification period and review selection.\"},{\"question\":\"What supporting documents are required according to the checklist?\",\"answer\":\"Provide a verbal or signed order with frequency and duration (when needed), a completed signed SOC OASIS for the first reauthorization request, and updated clinical documentation including ROC OASIS and signed 485/POC for services requested, plus visit notes and wound measurements if applicable.\"}]","Home Health Care Re-authorization Form - Request Submission | PDF",1789621097]