An authorization is a payer’s approval for a service, a number of hours, and a date range. It answers whether the payer will pay. It does not answer whether a caregiver will be in the home at 7 a.m. on Saturday, whether the hours fall when the client needs them, or who covers the hours the authorization leaves out. If nobody checks, the family finds these gaps after care starts.
This guide lists five checks a case manager can make before or at referral.
1. Do the authorized hours match the hours of need?
Map the client’s day: when they wake, bathe, eat, take medicines, and go to bed, and when they are alone. Compare it with the authorized hours. Ten hours a week spread over five weekday mornings is a different service from ten hours on two long days. Ask which pattern the client’s day needs.
2. Can the provider staff the pattern?
Ask the receiving provider directly whether it can staff the authorized hours on the days and times the client needs, and from what start date. Ask specifically about evenings, weekends, and minimum shift length.
3. Who covers the hours outside the authorization?
Many clients need hours that no payer approves. Name who covers the rest: a family member, a paid private arrangement, another program, or nobody. Write it down and tell the family. If the answer is nobody, that is a risk to record.
4. Is the home ready on day one?
Check that equipment has been ordered and will arrive before the first visit, that someone can let the caregiver in, and that the caregiver will have the client’s routine and contacts. OPA’s free Discharge Day worksheet covers this handoff.
5. Who owns the renewal?
Authorizations expire. Name who tracks the end date, who reassesses the client, and who submits the next request. When nobody owns the renewal, care can stop on the expiration date with no warning to the family.
A shared tool
OPA’s free What This Organization Owns worksheet asks, for each organization involved, what it delivers, what it does not, and what remains. Families and professionals can fill it in together. OPA’s family-facing guide, Insurance Approval and Home Support Are Different Questions, makes the same point for families.
A first step for your team
Add the five questions above to your referral checklist and ask them on your next referral.
To refer a client to OPA for care at home, see how care starts at OPA.
Payer rules change. Confirm current requirements before acting. Confirm a payer’s requirements with that payer.
