Home Health Services
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Defines AmeriHealth Caritas Delaware reimbursement guidelines, coverage considerations, and prior authorization expectations for home health services (Place of Service 12) for enrolled members.
No material clinical or coverage changes in this revision.
Home Health Coverage Criteria
Home health coverage criteria and billing rules
Covered when ALL of the following service-specific and billing expectations are met:
ALL of the following
- Skilled nursing services are covered when prescribed by a physician and medically necessary to restore or maintain the member's maximal level of function or health; services are rendered in the home in lieu of hospitalization, extended care facility confinement, or going outside the home for services.
- Physical, occupational, and speech therapy may be covered in the home when prescribed by a physician for homebound patients to improve, develop, or restore physical functions lost due to illness or injury.
- Home health aide services (non‑skilled personal care) are covered to assist with activities of daily living, prescribed exercise regimens that support skilled therapy (not requiring a therapist), non‑sterile dressing changes, routine prosthetic/orthotic care, supervision of self‑administered medications/special diets, and basic health monitoring.
- Durable medical equipment (DME) and medical supplies recommended by the physician and suitable for home use may be reimbursed if medically necessary.
- Hospice care is covered for members certified as terminally ill with a prognosis of 6 months or less who elect hospice instead of curative treatment; covered hospice services include nursing, social services, physician services, counseling, short‑term inpatient hospice care, therapies, appliances, supplies, and medications. Coordination with Utilization Management and physician certification are required.
Coding Sources and Requirements
| CPT | Current Procedural Terminology and associated publications and services. |
| ICD-10 | International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10). |
| HCPCS | Healthcare Common Procedure Coding System (HCPCS). |
| CMS | Centers for Medicare and Medicaid Services (CMS) - coding terminology and methodologies. |
| NCCI | The National Correct Coding Initiative (NCCI). |
| Delaware Medicaid Fee Schedule(s) | State-specific fee schedules used for reimbursement reference. |
Prior Authorization & Coordination
Obtain prior authorization and coordinate hospice with Utilization Management
Prior authorization is required for home health care and infusion therapy. For hospice, the primary care practitioner, attending physician, or hospice agency must contact AmeriHealth Caritas Delaware Utilization Management to coordinate care and obtain physician certification that the member is terminally ill (prognosis ≤ 6 months).
- Prior authorization required for home health care and infusion therapy; providers should refer to the provider manual or the prior authorization lookup link for requirements.
- For hospice, contact Utilization Management to arrange coordination of care and ensure hospice obtains physician certification of terminal illness (life expectancy ≤ 6 months) and that the member elects hospice instead of active treatment.
Definitions
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