CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Home Health Services

Defines coverage, prior authorization/notification requirements, clinical criteria for homebound status, covered and non-covered home health services, unit definition and limits, documentation required for authorization of ongoing services, applicable place-of-residence and part-time/intermittent definitions, and relevant billing codes for Blue Cross Blue Shield Rhode Island (BCBSRI) BlueCHiP for Medicare and Commercial Products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Home Health Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review Date

Key ActionVerify member eligibility and benefits, submit required notification to administratively authorize up to 30 units for up to 90 days, and follow prior authorization requirements for additional services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

30Initial units administratively authorized

90Initial days covered

2Home health aide hours per day (limit)

8Skilled services hours per day threshold (private nursing)

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Standard weekly hour limit for part-time/intermittent

Coverage Summary

This policy defines coverage for home health services including clinical criteria, prior authorization/notification requirements, unit and visit limits, and applicable billing codes for BCBSRI BlueCHiP for Medicare and Commercial products. Coverage is mixed and may vary by contract and the member's Evidence of Coverage; always refer to the member's Subscriber Agreement or Evidence of Coverage for specific benefits. Effective July 1, 2018, notification/authorization processes apply and initial administrative authorization is available for up to 30 units for up to 90 days.

Home health care includes skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, and home health aide services when provided as part of a skilled plan of care. Services that are custodial in nature (nonmedical personal care, homemaking, companionship, maintenance therapy) are a contract exclusion and may be excluded from coverage. Charges for private nursing are also addressed as a potential exclusion under related policies.

Coverage Thresholds and Limits — Home Health Services

Initial Administrative Authorization UnitsUp to 30 units of home health services for up to 90 days

Home health aide daily limit<= 2 hours per day (services over 2 hours/day subject to retrospective review and may be excluded as custodial care)

Skilled services daily limit<= 8 hours per day (skilled services alone beyond 8 hours/day may be considered private nursing and not home health)

Part-time/intermittent weekly hours<= 28 hours/week (case-by-case review may allow up to 35 hours/week)

Plan of care review intervalEvery 60 days

Request timingRequests for ongoing services must be submitted at least four business days prior to the visit that would be the 30th unit

Medical Necessity Criteria

Coverage — Homebound and Skilled Care Criteria (BlueCHiP for Medicare and Commercial Products)

Home health services are covered when ALL of the following criteria are met:

ALL of the following

Member is homebound based on one of: because of illness or injury needs the aid of supportive devices (crutches, canes, wheelchairs, walkers), use of special transportation, or the assistance of another person to leave their place of residence; OR leaving home is medically contraindicated.
Homebound definition includes patients who are not bedridden but have normal inability to leave home; absences must be infrequent/short or for receiving health care.
There must exist a normal inability to leave home; leaving home must require considerable and taxing effort.
If the member does leave home, they may still be considered homebound if absences are infrequent/short or for medical treatment (e.g., adult day medical care, outpatient chemo/radiation, dialysis).
Member is under the care of a provider (MD, DO, or Midlevel Practitioner).

Applicable Codes

Home health and related HCPCS/S codes (applicable)HCPCSCovered

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

Provider Actions & Prior Authorization

Prior Authorization

Notification for initial home health services

Effective July 1, 2018, notification is required/recommended for home health services, including the initial assessment/evaluation. The notification will administratively authorize up to 30 units of home health services for up to 90 days.

Administratively authorizes up to 30 units for up to 90 days
Effective date: July 1, 2018

Prior Authorization

Prior authorization for additional services

Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial Products for services beyond the initial 30 units/90 days. Requests for ongoing services must be submitted in advance for review of medical necessity.

Submit at least four business days before the visit that would be the 30th unit

Background & Definitions

Home health care covers a wide range of services including skilled nursing, physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), medical social services, and home health aide services that are directly related to a skilled plan of care. Covered services are those that require the expertise of a skilled professional and are reasonable in amount, frequency, and duration consistent with the member's condition.

Coverage and specific benefit details vary by group and contract; refer to the applicable Evidence of Coverage or Subscriber Agreement for member-specific benefits. For BlueCHiP for Medicare and Commercial Products, a unit of service is defined as each modality rendered (e.g., PT, OT, Nursing) and BCBSRI will administratively authorize up to 30 units for up to 90 days upon notification of the initial evaluation.

Home health aide services are covered when directly related to the skilled plan of care and are typically limited to up to 2 hours per day; services exceeding 2 hours per day will be retrospectively reviewed and may be excluded if determined to be custodial care as defined by Medicare. Custodial care, homemaking, personal care attendant services, maintenance therapy, and charges for private nursing are contract exclusions and not covered.

Term	Definition
Unit	Each modality rendered (e.g., PT, OT, Nursing) is defined as one unit of service.
Homebound	Condition due to illness or injury that restricts ability to leave residence except with aid of supportive device, special transportation, or another person, or leaving is medically contraindicated; absences must be infrequent/short or for medical treatment.
Part-time or intermittent services	Skilled nursing and home health aide services combined less than 8 hours per day and 28 or fewer hours per week (or case-by-case up to 35 hours/week).
Custodial care	Services for nonmedical personal care to help with activities of daily living (e.g., getting in/out of bed, bathing, eating), homemaking, companionship, or maintenance therapy; contract exclusion.

References: Medicare Benefit Policy Manual Chapter 7; Medicare Claims Processing Manual Chapter 10; 42 CFR 424.22; BCBSRI Subscriber Agreement Section 3.15.

Medicare Determinations

Name	Type	Number	Effective
Medicare Benefit Policy Manual: Home Health Services	NCD

Revision History

2018-07-01effective

Policy effective date (Medical Coverage Policy Home Health Services effective July 1, 2018).

2018-04-17last_reviewLatest

Policy last updated/reviewed on April 17, 2018.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Home Health Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review Date

SourceLink

On This Page

Member is receiving services under a plan of care established and periodically reviewed by a provider (every 60 days).

Care is inherently complex such that it can be performed safely and effectively only by or under the supervision of a skilled therapist or nurse.

Member needs skilled nursing on an intermittent basis OR physical therapy OR speech-language pathology OR continuing need for occupational therapy.

Services must be reasonable in amount, frequency, and duration and consistent with nature/severity of illness or injury.

Services are considered specific, safe, and effective treatments for the member's condition under standards of medical practice.

Part-time or Intermittent Services Definition

Definition used for coverage limits:

Part-time or intermittent means skilled nursing and home health aide services furnished any number of days per week as long as combined they are less than 8 hours each day and 28 or fewer hours each week.

Subject to case-by-case review, the weekly limit may be extended to less than 8 hours per day and 35 or fewer hours each week.

Documentation Required

Documentation required for authorization review

The documentation submitted for authorization review must include clinical and plan-of-care information to support continued services.

Initial evaluation results
Evidence of homebound status
Individualized plan of care goals
Number of visits needed and duration
For each discipline, goals met and not met
Barriers identified that will impact the member’s ability to meet unmet goals
Progress made toward any unmet goals
Plan to address those barriers, including provider follow-up
Anticipated number of visits needed to meet goals

Billing Rule

Unit definition

For this policy, a unit of service is defined as each modality rendered (e.g., PT, OT, and Nursing).

Denial Risk

Custodial care exclusion risk

Services determined to be custodial care (non-medical personal care, homemaking, companionship, maintenance therapy) or charges for private nursing are contract exclusions and may be excluded from coverage; such services may be billed to the member only if the member was informed and agreed in writing.

Documentation Required

Verify eligibility and benefits

The home health care provider is responsible for verifying the member’s eligibility and benefit coverage and submitting the required notification for home health services.

Verify member eligibility and benefit coverage
Submit required notification (including initial assessment/evaluation)