HMO & Managed Care Support

Authorization Requests, Follow-Up & Care Coordination

We provide dedicated support for HMO and Managed Care processes to help agencies streamline administrative tasks, maintain compliance, and ensure timely patient care. Our team assists with authorization management, payer communication, and ongoing followup to support efficient service delivery.

Authorization Requests

We assist with the preparation and submission of authorization requests required by HMO and managed care plans. Our team works closely with clinical staff to ensure requests include the necessary documentation and clinical justification.

Services include:

  • Preparation and submission of authorization requests
  • Verification of patient eligibility and coverage
  • Documentation review to support medical necessity
  • Coordination with physicians and care teams for required information

Timely authorization processing helps prevent delays in patient care and billing.

Authorization Follow-Up

Our team actively tracks submitted authorization requests to ensure prompt approval and minimize service interruptions.

Follow-up services include:

  • Monitoring authorization status with payers
  • Communicating with insurance representatives
  • Addressing additional documentation requests
  • Escalating urgent cases when necessary
  • Updating care teams regarding approval status

Consistent follow-up helps ensure that services are delivered according to approved care plans.

Managed Care Coordination

We help agencies navigate complex managed care requirements while maintaining accurate documentation and compliance.

Support may include:

  • Communication with HMO case managers
  • Verification of visit frequencies and authorized services
  • Coordination of care updates with insurance providers
  • Assistance with authorization extensions or modifications
  • Documentation tracking related to payer requirements

Consistent follow-up helps ensure that services are delivered according to approved care plans.

HMO & NGS Billing Support

Home Health and Hospice Billing Services

We provide comprehensive billing support for HMO (Managed Care) and NGS Medicare claims to help home health and hospice agencies maintain accurate billing, reduce claim denials, and ensure regulatory compliance.

Our team supports agencies through the entire billing process—from eligibility verification and authorization management to claim submission and follow-up.

HMO Billing Support

Home Health and Hospice Billing Services

Managing HMO and managed care billing requires careful coordination with insurance providers and adherence to authorization requirements. Our services help agencies navigate complex payer guidelines while ensuring services are billed correctly

Our HMO billing services include:

  • Patient insurance verification and eligibility review
  • Authorization request submission for skilled services
  • Monitoring authorization status and approvals
  • Billing claims to HMO and managed care plans
  • Denial management and claim correction
  • Communication with payer representatives
  • Verification of visit frequencies and authorized services

Our goal is to help agencies avoid delays in reimbursement while maintaining compliance with payer policies.

NGS Medicare Billing Support

We provide billing assistance for agencies submitting Medicare claims through NGS (National Government Services), one of the Medicare Administrative Contractors responsible for processing Medicare claims and providing billing guidance to providers.

Our NGS billing support includes:

  • Notice of Admission (NOA) submission
  • Medicare eligibility verification
  • Home health period of care claim billing
  • Billing claims to HMO and managed care plans
  • Claim preparation and electronic submission
  • Billing under the Home Health Prospective Payment System (HH PPS)
  • Review of diagnosis coding and documentation alignment
  • Claim status tracking and resolution of rejections

Under Medicare home health billing rules, agencies must submit required claims such as the Notice of Admission (NOA) and period of care claims to open and process a home health episode

Claims Follow-Up & Denial Management

Our team actively monitors claim submissions and provides follow-up to ensure timely reimbursement.

Services include:

  • Claim status monitoring
  • Correction of rejected or returned claims
  • Appeal assistance for denied claims
  • Communication with Medicare and insurance representatives
  • Documentation review to prevent future billing issues

Under Medicare home health billing rules, agencies must submit required claims such as the Notice of Admission (NOA) and period of care claims to open and process a home health episode

Development & Review of the CMS-485 / Plan of Care (Care Plan)

We support agencies with accurate, compliant CMS-485 Plan of Care (POC) development and review to ensure services are clinically appropriate, properly ordered, and aligned with patient goals and physician requirements.

Our process helps strengthen documentation, improve care coordination, and support timely billing and authorizations.

CMS-485 / Care Plan Development

We assist in developing a complete, patient-specific Plan of Care that reflects the patient’s condition and supports medical necessity.

Includes:

  • Patient diagnoses and clinical narrative alignment
  • Skilled need justification and measurable goals
  • Ordered disciplines and services (SN/PT/OT/ST/MSW/HHA)
  • Visit frequencies, durations, and interventions
  • Safety planning, medication profile support, and teaching needs
  • Coordination elements needed for physician signature and payer review

CMS-485 / Care Plan Review (QA + Compliance)

We provide thorough review of existing CMS-485/Care Plans to ensure consistency and compliance across documentation.

We review for:

  • Alignment with physician orders and Start of Care/Recert documentation
  • Accuracy of visit frequencies and ordered services
  • Consistency with clinical notes, progress, and outcomes
  • Appropriate interventions tied to diagnoses and goals
  • Missing or conflicting information that may cause denials or delays
  • Proper documentation of changes and updates to the Plan of Care

RN Case Management

Coordinated Care with Nurses, Physicians, and HMOs

our RN Case Managers work closely with field nurses, physicians, and HMO care coordinators to ensure that every patient receives safe, coordinated, and effective care

Our RN case management team serves as a central point of communication between healthcare providers, insurance plans, and the home health team. This collaborative approach helps ensure that patient care follows the approved Plan of Care, physician orders, and insurance authorization requirements.

Our RN Case Managers:

  • Collaborate with field nurses to monitor patient progress and care needs
  • Communicate regularly with physicians regarding patient status, orders, and treatment updates
  • Coordinate with HMO and managed care plans for authorizations and service approvals
  • Ensure services are delivered according to the Plan of Care and visit frequencies
  • Identify changes in patient condition and report them promptly to the care team
  • Support documentation accuracy and regulatory compliance

Through strong coordination and communication, RN case management helps improve patient outcomes, reduce care delays, and maintain continuity of care.