CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Home Health Services — Skilled

Defines coverage, medical necessity criteria, authorization/notification requirements, covered and non-covered home health skilled services for BCBSRI Medicare Advantage and Commercial products and what providers must submit to obtain or continue coverage.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHome Health Services — Skilled

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2018

Next Review DateN/A

Key ActionSubmit notification to administratively approve up to 30 units/90 days and request prior authorization for services beyond that.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 units / 90 daysadministrative approval on notification

Up to 8 hrs/dayprivate nursing threshold

2 hrs/daytypical home health aide limit

60 daysplan of care review interval

Coverage Criteria

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Medical necessity criteria

Covered when ALL of the following are met:

Home health medical necessity: 1) Patient is homebound as defined; AND 2) Under the care of a provider (MD, DO, or midlevel practitioner) with a plan of care established and reviewed periodically (every 60 days); AND 3) Needs intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy; AND 4) Care is reasonable in amount, frequency, and duration and is specific, safe, and effective for the condition; AND 5) Care is inherently complex such that it can be performed safely and effectively only by or under the general supervision of a skilled therapist or nurse.

Derived from numbered medical criteria in source

Coding and Billing

Covered HCPCS S-codesHCPCSCovered

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

Alternate/Not applicable local G-codesHCPCS

G0150	Services of Occupational Therapist in home health setting, each 15 minutes
G0151	Services of Physical Therapist in home health setting, each 15 minutes
G0153	Services of Speech and Language Pathologist in home health setting, each 15 minutes
G0156	Services of Home Health Aide in home setting, each 15 minutes
G0157	Services performed by qualified physical assistant in the home health setting, each 15 minutes
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0158	Services performed by a qualified occupational therapy assistant in the home health setting, each 15 minutes
G0300	Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes

inv-06: Part-time or intermittent hours — definition/thresholds

DefinitionPart-time or intermittent services means combined skilled nursing and home health aide services furnished less than 8 hours each day and 28 or fewer hours each week (subject to case-by-case review).

Daily thresholdLess than 8 hours per day combined skilled nursing and home health aide services.

Weekly threshold28 or fewer hours per week combined skilled nursing and home health aide services (subject to case-by-case review).

Case review noteHours exceeding these thresholds may be reviewed on a case-by-case basis to determine medical necessity (may consider alternate threshold wording in source: 'less than 8 hours each and 35 or fewer hours each week' in some reviews).

Provider Actions & Authorization

Prior Authorization

Notification and Prior Authorization

Effective July 1, 2018, notification is required (and will administratively authorize) up to 30 units of home health services for up to 90 days. Prior authorization is required for services beyond 30 units or beyond 90 days. Prior authorization and notification are required for Medicare Advantage Plans and recommended for Commercial Products. The home health care provider is responsible for verifying member eligibility, benefit coverage, and submitting the required notification.

Notification/administrative approval: up to 30 units / 90 days
Prior authorization required for services beyond 30 units or beyond 90 days
Required for Medicare Advantage; recommended for Commercial products
Providers must verify eligibility and submit notification

Documentation Required

PROVIDER ACTIONS (submission requirements)

Providers must submit required documentation when requesting ongoing home health services. Requests for ongoing services should be submitted at least four business days prior to the visit that would exceed the 30th unit or the 90-day period. Documentation must include the initial evaluation results, evidence of homebound status, individualized plan of care and goals, number of visits needed and expected duration, progress toward goals (met and unmet), barriers impacting goal achievement and the plan to address them (including follow-up with the ordering provider), and the anticipated number of visits needed to meet goals. When barriers to progress are identified, documentation of provider follow-up is required.

Submit at least 4 business days prior to the visit that would exceed the 30th unit/90th day
Include initial evaluation results and evidence of homebound status
Include individualized plan of care and goals
Specify number of visits needed and expected duration
Document progress toward goals, unmet goals, and barriers
Provide plan to address barriers and provider follow-up documentation
State anticipated number of visits needed to meet goals

Denial Risk

Retrospective Review and Non‑covered / Excluded Services

Services that exceed the aide limits (home health aide typically limited to 2 hours per day) or services that appear to be custodial in nature will be subject to retrospective review. Home health aide services are covered when directly related to the skilled plan of care and are typically not required for more than 2 hours per day. Services over the 2-hour-per-day limit may be reviewed and, if determined to be custodial care (non-skilled personal care or homemaking), will be excluded from coverage. Custodial care includes help with activities of daily living (bathing, dressing, eating, transferring, toileting), homemaking, companionship, or maintenance therapy. Providers should be aware that skilled nursing services alone should not exceed 8 hours per day (may be considered private duty nursing) — refer to the Private Duty Nursing policy for guidance.

Home health aide services generally limited to 2 hours per day; overages subject to retrospective review
Services deemed custodial (ADLs, homemaking, companionship, maintenance therapy) are excluded from coverage
Skilled nursing services alone should not exceed 8 hours per day; see Private Duty Nursing policy
Retrospective review may result in denial/payment exclusion if services are custodial

Denial Risk

Payment Risk for Missing Notification / Authorization

Failure to submit the required notification or obtain prior authorization (when required) may result in denial of payment. Providers must follow the notification/prior authorization process through the BCBSRI online tool for participating providers and ensure valid authorizations are present for dates of service on or after February 1, 2019.

Lack of required notification or prior authorization may lead to claim denial
Valid authorization required for dates of service on or after 2019-02-01

Definitions

inv-13: Homebound — definition of home confined/homebound

DefinitionA patient is considered homebound if a condition due to illness or injury restricts their ability to leave their place of residence except with the aid of supportive devices, special transportation, or the assistance of another person, or if leaving home is medically contraindicated.

Not bedridden requirementPatient need not be bedridden to be considered homebound; the condition must cause a normal inability to leave home and leaving would be a considerable and taxing effort.

Permitted absencesInfrequent or short absences or absences for receiving healthcare (e.g., adult day medical care, outpatient chemotherapy/radiation, ongoing dialysis) do not preclude homebound status.

inv-14: Place of Residence — what qualifies as place of residence

DefinitionPlace of residence is wherever the patient makes his or her home, including their own dwelling, an apartment, a relative's home, an assisted living facility, group home, or personal care home.

IncludesOwn home, apartment, relative's home.

Includes facilitiesAssisted living facility, group home, or personal care home.

inv-15: Part-time or Intermittent — definition and hour thresholds

DefinitionPart-time or intermittent: combined skilled nursing and home health aide services furnished less than 8 hours each day and 28 or fewer hours each week (subject to case-by-case review).

Daily limitLess than 8 hours per day combined skilled nursing and home health aide services.

Weekly limit28 or fewer hours per week combined skilled nursing and home health aide services (subject to case-by-case review).

Review provisionSubject to review on a case-by-case basis to determine need for care if hours approach or exceed thresholds.

OpenPayer

Home Health Services — Skilled

Coverage Criteria

Coding and Billing

Provider Actions & Authorization

Definitions

Background