CurrentAlliance HealthPolicy 1M-5

Home visit for postnatal assessment and follow-up care

Defines Medicaid coverage, eligibility, provider qualifications, timing, clinical and documentation requirements, billing and reimbursement rules for one-to-one RN home visits for postnatal assessment and follow-up care for postpartum Medicaid beneficiaries in North Carolina.

Policy Summary

PayerAlliance Health

PolicyHome visit for postnatal assessment and follow-up care

Policy CodePolicy 1M-5

Change TypeTemplate updatesadministrative revisions

Effective DateOct 1, 2002

Next Review Date

Key ActionProvider must verify each Medicaid beneficiary's eligibility each time a service is rendered.

SourceLink

POLICY UPDATE CHANGES

Policy posted 8/15/2023 with an effective date of 04/01/2023 reflecting NC Health Choice move to Medicaid and template updates.

05/15/2022 changes: removed postpartum definition; replaced 'to' with 'or' in Section 3.2.2; added encouragement to render services close to delivery.

Multiple historical revisions (2005-2019) updated EPSDT language, billing guidance, and moved billing guidelines to attachments.

1Visit per pregnancy allowed

60Post-delivery coverage window (days)

RNRequired provider

CMS-1500/UB-04

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Coverage Summary

Overview: This policy (Policy Number 1M-5) covers one-to-one RN home visits for postnatal assessment and follow-up care for postpartum Medicaid beneficiaries in North Carolina. Coverage stance: covered_with_criteria. Scope: defines Medicaid eligibility and provider qualifications (RN), documentation and coordination requirements, and billing rules for home visits conducted in the beneficiary's home.

Timing and frequency thresholds: Home visits are covered if they occur within two to three weeks following the client's discharge or no later than 60 days after delivery. Billing frequency is limited to one visit per pregnancy and visits must be billed per date of service. Professional claims use CMS-1500/837P (institutional claims per UB-04 when directed).

Key thresholds and quick facts

Timing from deliveryWithin 2-3 weeks post-discharge or no later than 60 days after delivery

Billing frequencyOne visit per pregnancy (billed once per client per pregnancy)

Required provider licensureService must be rendered by a registered nurse (RN)

Claim formsProfessional claims: CMS-1500/837P; Institutional claims: UB-04 per National Uniform Billing Guidelines

Medical Necessity & Coverage Criteria

General Medical Necessity Criteria

Covered when ALL of the following are met:

Medically necessary: The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs
Must be individualized, specific, consistent with symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs
Safety and conservativeness: The procedure, product, or service can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide
No equally effective and more conservative or less costly treatment available statewide
Not for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, caretaker, or provider

Exclusions, EPSDT, and Special Provisions

Not Covered - General Exclusions

Not covered when ANY of the following apply:

Ineligible beneficiary: Beneficiary does not meet the eligibility requirements listed in Section 2.0
Beneficiary does not meet eligibility requirements
Fails Section 3.0 criteria: Beneficiary does not meet the criteria listed in Section 3.0
Beneficiary does not meet the criteria listed in Section 3.0
Duplication of services: Procedure, product, or service duplicates another provider's procedure, product, or service
Procedure, product, or service duplicates another provider's procedure, product, or service

Coding and Billing Forms

Primary ICD-10 Diagnosis Codes (examples listed)ICD-10

Z39.0	Encounter for care and examination of mother immediately after delivery
Z39.2	Encounter for routine postpartum follow-up

Procedure / CPT / HCPCS / Unlistedmixed

Unlisted CPT/HCPCS

If no specific CPT or HCPCS code exists, report the appropriate unlisted procedure/service code and follow CPT/HCPCS special report instructions

Claims Type and Billing Formmixed

CMS-1500/837P	Professional claims
UB-04	Institutional claims billed per National Uniform Billing Guidelines when directed

Provider Actions and Billing Rules

Documentation Required

Verify Medicaid eligibility

Provider must verify each Medicaid beneficiary's eligibility each time a service is rendered.

Documentation Required

Follow curriculum and document findings

Visit must follow the DEHNR T775 Rev. 3/93 curriculum. RN must document findings in the mother's and child's records as applicable and discuss/update plans of care with Pregnancy Care Manager and/or Care Coordination for Children Care Manager.

Billing Rule

Billing units and frequency

Background

Background and goals: Home visits for postnatal assessment deliver health, social support, and education directly in the family's home to follow up on the mother's health, counsel on family planning and infant care, arrange additional appointments, and make referrals as needed.

Primary objectives: provide early preventive and anticipatory services; enable timely referral of problems; promote spacing of subsequent pregnancies; and provide a link to women's preventive health services.

Visit activities: visits must include assessment, counseling, teaching, and referral as needed, follow the Postpartum Home Visit Assessment curriculum (DEHNR T775 Rev. 3/93), and be conducted one-to-one, face-to-face in the client's home.

Definitions

EPSDTEarly and Periodic Screening, Diagnostic, and Treatment — federal Medicaid requirement to cover medically necessary services for beneficiaries under 21 to correct or ameliorate health problems.

Revision History

08/15/2023policy_postedLatest

Policy posted 8/15/2023 with an effective date of 04/01/2023 reflecting NC Health Choice move to Medicaid and updated template language.

05/15/2022amendment

Policy amended 05/15/2022 with effective date 04/01/2022; removed postpartum definition, replaced 'to' with 'or' in Section 3.2.2, and added encouragement to render services close to delivery.

2005-2019administrative_updates

Policy Summary

PayerAlliance Health

PolicyHome visit for postnatal assessment and follow-up care

Policy CodePolicy 1M-5

Change TypeTemplate updatesadministrative revisions

Effective DateOct 1, 2002

Next Review Date

Key ActionProvider must verify each Medicaid beneficiary's eligibility each time a service is rendered.

SourceLink

On This Page

Not primarily intended for the convenience of beneficiary, caretaker, or provider

Eligibility verification: Beneficiary meets Medicaid eligibility requirements in Section 2.0 and provider verifies eligibility each time service is rendered

Provider must verify Medicaid eligibility at each service

Specific Medicaid Additional Coverage Criteria

Covered when ANY of the following timing criteria are met:

Timing criteria

Within 2-3 weeks post-discharge: Home visit occurs within two to three weeks following the client's discharge from the hospital
No later than 60 days: Home visit occurs no later than 60 days after delivery

Visit Format and Content Requirements

Required visit characteristics:

One-to-one face-to-face in-home: Visit must be a one-to-one, face-to-face visit conducted in the client's home
Assessment, counseling, teaching, referral: Visit must include assessment, counseling, teaching, and referral as needed
Follow curriculum: Visit must follow the curriculum requirements on the Postpartum Home Visit Assessment form (DEHNR T775 Rev. 3/93)

Providers are encouraged to render services as close to delivery as possible.

RN Responsibilities and Coordination

RN must perform the following actions (when applicable):

Pre-visit coordination: Discuss past and current medical history and plan of care/service coordination goals with the Pregnancy Care Manager and/or Care Coordination for Children Care Manager prior to the home visit
Discuss past/current medical history and plan of care/service coordination goals
Scheduling and explanation: Contact the family to schedule a convenient time for the home visit and explain its purpose
Documentation after visit: Document findings in the mother's record and in the child's record as they apply after the visit
Document findings in mother's and child's records as applicable after the visit
Post-visit communication: Discuss observations with the Pregnancy Care Manager and/or Care Coordination for Children Care Manager and update the plan of care as applicable
Discuss observations with care managers and update plan of care as applicable
Referrals: Make referrals to other agency and community resources as indicated
Make referrals to other agency and community resources as indicated
Record review when child not eligible for CCC: If child is not eligible for Care Coordination for Children but mother is in Pregnancy Care Management, RN must review available referral records and prior medical records prior to visit
If child not eligible for Care Coordination for Children but mother is in Pregnancy Care Management, RN must review available referral records and prior medical records prior to visit
RN may serve as care manager: An RN who is the family's Pregnancy Care Manager and/or Care Coordination for Children Care Manager may make the home visit in lieu of or in addition to regularly scheduled management activities; coordination between programs is required
Coordination between Pregnancy Care Management and Care Coordination for Children required to avoid duplication

Coordination note: Coordination of care strategies must be identified by all caregivers to avoid duplication of services.

Experimental or investigational: Procedure, product, or service is experimental, investigational, or part of a clinical trial

Procedure, product, or service is experimental, investigational, or part of a clinical trial

EPSDT Exception

EPSDT special provision (beneficiaries under 21):

EPSDT Exception: EPSDT requires coverage of medically necessary services for beneficiaries under 21 to correct or ameliorate a defect, illness, or condition

EPSDT does not eliminate the requirement for prior approval if a service normally requires it

One visit per pregnancy. Must bill per date of service. A home visit for postnatal assessment and follow-up care is reimbursed once per client per pregnancy.

Billing Rule

Claim forms

Professional claims must use CMS-1500/837P. Institutional claims must be billed per UB-04 National Uniform Billing Guidelines when directed.

Allowed forms: CMS-1500/837P (professional)
UB-04 (institutional)

Documentation Required

Provider qualifications and enrollment

Providers must meet Medicaid qualifications for participation, have a current signed DHHS Provider Administrative Participation Agreement, and bill only within the scope of their clinical licensure.

Documentation Required

RN required to render service

Service must be rendered by a registered nurse (RN). Federally Qualified Health Centers, local health departments, and Rural Health Clinics are eligible providers.

Billing Rule

Place of service and copay

Place of service is the beneficiary's home. Co-pay rules follow the Medicaid State Plan (see Medicaid State Plan notices for copayment details).

Billing Rule

Reimbursement interactions

A home visit for postnatal assessment and follow-up care and a home visit for newborn care may both be reimbursed when provided on the same date of service. Pregnancy Care Management/Care Coordination for Children PMPM reimbursement rules still apply where relevant.

Multiple historical revisions (2005–2019) updated EPSDT language, billing guidance, moved billing guidelines to attachments, added PHP notice in 2019, and applied template updates.