Home Health Services - Skilled
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Defines coverage, prior authorization/notification, limits, and medical necessity criteria for skilled home health services for Blue Cross Blue Shield - Rhode Island members. Applies to providers delivering home health skilled care (not hospice).
No material clinical or coverage changes in this revision.
Coverage criteria for skilled home health services
General coverage criteria (BlueCHiP for Medicare and Commercial Products)
Home health services are covered when ALL of the following are met:
General coverage criteria
1) Homebound
a or b
- a) Supportive devices/special transportation/assistance: Because of illness or injury, the member needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.
- b) Medically contraindicated to leave home: The member has a condition such that leaving his or her home is medically contraindicated.
c) And both of the following
- i) Normal inability to leave home: There must exist a normal inability to leave home.
- ii) Leaving home requires considerable and taxing effort: Leaving home must require a considerable and taxing effort.
- 2) Under care of a provider: The member is under the care of a provider (MD, DO, or Midlevel Practitioner).
- 3) Plan of care: Receiving services under a plan of care established and periodically (every 60 days) reviewed by a provider.
- 4) Need for skilled services: Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy.
- 5) Complexity of care: Care is inherently complex such that the services can be performed safely and/or effectively only by or under the general supervision of a skilled therapist or nurse.
- 6) Reasonable in amount/frequency/duration: Services are consistent with the nature and severity of the illness or injury and the patient’s particular medical needs; services are reasonable in amount, frequency, and duration.
- 7) Accepted as specific, safe, and effective: Services are considered specific, safe, and effective treatment for the member’s condition under standards of medical practice.
The following services are not covered: custodial care (services provided primarily to assist with activities of daily living such as bathing, dressing, meal preparation, feeding, ambulation, transferring, toileting, companionship, or homemaking), homemaking, and maintenance therapy. Also excluded are services provided by a personal care attendant and charges for private duty nursing.
Home health aide services are covered up to 2 hours per day; requests for services exceeding this limit will be retrospectively reviewed and, if judged to be custodial in nature, will be excluded from coverage. Skilled nursing provided in the home must not exceed 8 hours per day; skilled nursing that exceeds this threshold is considered private duty nursing and is a non-covered service.
Coding and limits for home health services
| S9122 | Home health aide or certified nurse assistant, providing care in the home |
| S9123 | Nursing care, in the home; by registered nurse |
| S9124 | Nursing care, in the home; by licensed practical nurse |
| S9127 | Social work visit, in the home, per diem |
| S9128 | Speech therapy, in the home, per diem |
| S9129 | Occupational therapy, in the home, per diem |
| S9131 | Physical therapy; in the home, per diem |
| S9470 | Nutritional counseling, dietitian visit |
Authorization, documentation, and provider responsibilities
Prior notification/authorization required — administrative approval of initial 30 units
Effective July 1, 2018, providers must submit prior notification for home health services; upon receipt BCBSRI will administratively authorize payment for up to 30 units of home health services spanning a period of 90 days. Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial products; additional services beyond the initial allocation require a prior-authorization review and must be requested at least four business days before the 30th unit visit.
- Notification administratively authorizes up to 30 units over 90 days.
- Prior authorization required for BlueCHiP for Medicare; recommended for Commercial products.
- Requests for additional services must be submitted ≥4 business days prior to the visit with the 30th unit.
Documentation required for prior-authorization review
When requesting ongoing services for prior-authorization review, submit the initial evaluation results, evidence of homebound status, the individualized member goals and plan of care, number of visits and duration, for each discipline goals met/unmet and progress toward unmet goals, any barriers identified and the plan to address them (including provider follow-up), and the anticipated number of visits needed.
- Initial evaluation results and evidence of homebound status
- Individualized member goals and plan of care; number and duration of visits needed
- Per-discipline goals met/unmet and progress toward unmet goals
- Identified barriers and plan to address them, including documentation of provider follow-up
- Anticipated number of visits needed
Provider must verify eligibility and submit notification/authorization
The home health care provider is responsible for verifying the member's eligibility and benefit coverage and must submit the required notification/authorization through BCBSRI processes.
- Verify member eligibility and benefits before services.
- Submit required notification/authorization via the BCBSRI online tool for participating providers.
Valid authorization required for claims on/after Feb 1, 2019
Payment of claims with dates of service on or after February 1, 2019 will be subject to the presence of a valid authorization from the plan; absence of a valid authorization may result in claim payment denial.
- Ensure a valid authorization is on file for claims dated on/after 2019-02-01.
Excluded services that will trigger denial
Services that are custodial in nature (e.g., homemaking, nonmedical personal care, companionship), services of a personal care attendant, and charges for private duty nursing are contract exclusions and may be denied.
- Custodial care, homemaking, maintenance therapy, and companionship are non-covered.
- Services of a personal care attendant are excluded.
- Charges for private duty nursing are excluded; skilled nursing services exceeding 8 hours per day are considered private duty nursing.
Background and scope
Skilled home health services include nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, and home health aide services when those aides are providing care directly related to the skilled plan of care. Covered skilled services must be reasonable in amount, frequency, and duration, and require the expertise of a licensed nurse or therapist. The policy notes that skilled nursing alone must not exceed 8 hours per day and that home health aide services are generally not required for more than 2 hours per day.
Definitions used in this policy
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