Prior Authorization in Home Care

Prior authorization in home care is the payer requirement to approve services before they are delivered or paid, and it varies sharply by payer. Traditional Medicare home health uses no standard prior authorization but applies pre-claim or postpayment review under the Review Choice Demonstration (RCD) in select states, while Medicaid home- and community-based services (HCBS) and managed-care plans commonly do require it.

For traditional Medicare home health, CMS operates the Review Choice Demonstration rather than blanket prior authorization. RCD continues in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma, and was extended for an additional five years effective June 1, 2024 ^[1]. Agencies choose pre-claim review or postpayment review; a claim that clears pre-claim review with a valid unique tracking number is excluded from further medical review. CMS reported roughly 1.84 million pre-claim review requests for home health in FY 2023, of which about 97 percent received provisional affirmation. Medicaid home care operates differently and is state-administered, so service authorization is typically tied to an assessment and plan of care and its specifics vary by state and program. A related authorization-adjacent control is Electronic Visit Verification: Section 12006(a) of the 21st Century Cures Act requires states to use EVV for Medicaid personal care services and home health services, capturing who delivered the service, to whom, and the visit start and end times ^[2]. States had to require EVV for personal care services by January 1, 2020 and for home health services by January 1, 2023, or face incremental Federal Medical Assistance Percentage (FMAP) reductions of up to 1 percent. EVV does not authorize a service, but unverified visits routinely fail payment even when the service itself was authorized.

The operational mistake is running one authorization playbook across a book of business governed by three different rulebooks. A Medicare home health episode in an RCD state, a Medicaid HCBS waiver case, and a managed-care member each fail for different reasons, and a workflow tuned to one will quietly bleed the others. RCD's roughly 97 percent provisional-affirmation rate shows the demonstration is passable with disciplined documentation, so recurring non-affirmations are a documentation-quality problem, not an arbitrary payer obstacle. On the Medicaid side, EVV is the quiet cash-flow killer — a properly authorized visit still goes unpaid if the visit data is missing or mismatched. Because Medicaid rules vary by state, national agencies operating across multiple states face payer- and state-specific authorization requirements that a single standard cannot accommodate.