ModifiedColorado Rocky Mountain Health PlansPolicy CS137OH.D

Home Health, Skilled, and Custodial Care Services (for Ohio Only)

Defines coverage, coding, and application rules for home health, skilled, and custodial care services for members in Ohio; applies to providers requesting authorization or billing for home-based services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.D

Change TypeCodes removedreferences updated

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and document medical necessity per InterQual LOC Home Care and Ohio Administrative Code 5160-101.

SourceLink

POLICY UPDATE CHANGES

Removed HCPCS codes S9339 and T1031 from applicable codes.

Removed reference link to the Medical Policy titled Home Hemodialysis (for Ohio Only) (retired May 1, 2026).

Updated References section to reflect the most current information.

100+Listed HCPCS/CPT/S codes referenced

Ohio onlyState applicability

InterQual LOCClinical criteria source

numerousHome health billing codes described

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

General medical necessity requirement

Covered when ALL of the following are met per InterQual and Ohio rule

State and criteria compliance: Service request is for a member in Ohio and medical necessity is supported by InterQual LOC: Home Care (Adult or Pediatric) and Ohio Administrative Code 5160-101 (or other applicable OAC rules) as required.

See InterQual LOC: Home Care Q & A for specific clinical criteria; when InterQual does not apply, UnitedHealthcare criteria approved by Ohio Medicaid may be used.

Skilled Home Health Medical Necessity

Home health services (skilled) are covered when ALL of the following criteria are documented:

Skilled home health coverage criteria: 1) A treating practitioner (MD, DO, PA, or NP) has prescribed the home health services; 2) Services are delivered in the member's residence; 3) Services are medically necessary skilled care provided by licensed health care professionals to restore or maintain function or to manage a condition (examples: medical/psychological evaluation, wound care, medication teaching, pain management, disease education and management, physical/speech/occupational therapy) and are not custodial in nature; 4) State or contractual provision requirements and any applicable visit limitations per Ohio Administrative Code (e.g., OAC Rule 5160-12-01) are met.

Documentation must support skilled need vs custodial care; follow InterQual LOC Home Care for clinical detail and OAC/contractual rules for visit limits and provision requirements.

This Medical Policy applies only to services provided to members located in the state of Ohio. Requests for services delivered outside Ohio are excluded from the coverage rules in this policy. Any request for services described as unproven or subject to coverage or quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-101.

Custodial care services are non-medical supports that assist with personal care and activities of daily living such as bathing, dressing, ambulation, toileting, housekeeping, cooking, laundry, or supervision of self-administered medication. These services are distinguished from skilled care services and are considered non-skilled when they can be reasonably and safely provided by non-licensed caregivers; custodial care is not covered as skilled home health.

Services described in this policy as unproven, or services for which there are coverage or quantity limits, will be reviewed for medical necessity and may be denied if they do not meet applicable criteria. Medical necessity determinations for such services will follow Ohio Administrative Code 5160-101 as part of the evaluation.

Purely non-medical or custodial services do not meet the definition of skilled home health and are not eligible for coverage as skilled services. Additionally, FDA approval alone is not a basis for coverage; FDA status is informational only and does not substitute for documentation that the service meets medical necessity requirements and is skilled in nature.

Billing Codes and Service Setting

CPT Home visit codes (examples)CPT

99500	Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
99501	Home visit for postnatal assessment and follow-up care.
99502	Home visit for newborn care and assessment.

HCPCS/Medicare G, S, T codes and other home therapy codesmixed

G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other IV infusion drug or biological, each 15 minutes.
G0070	Professional services for the administration of IV chemotherapy or other highly complex drug or biological infusion, each 15 minutes.
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes.
G0320	Home health services furnished using synchronous telemedicine via real-time two-way audio and video.
S9340	Home therapy; enteral nutrition; per diem.
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment.
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
T1001	Nursing assessment/evaluation.

1–10 of 11

1/2

Covered HCPCS/T codes for home health servicesHCPCSCovered

S9538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem
S9542	Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9560	Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9562	Home injectable therapy, palivizumab or other monoclonal antibody for RSV, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9590	Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
T1001	Nursing assessment/evaluation
T1002	RN services, up to 15 minutes
T1003	LPN/LVN services, up to 15 minutes
T1004	Services of a qualified nursing aide, up to 15 minutes

1–10 of 15

1/2

inv-10: Service setting — Services provided in the member's residence

Service settingServices provided in the member's residence

Authorization, Documentation, and Utilization Review

Documentation Required

Authorization and Documentation Requirements

Prior authorization and medical necessity determinations follow InterQual LOC: Home Care criteria and Ohio Administrative Code requirements. Requests for services that are stated as unproven or that have coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101 and Rule 5160-12-01 as applicable. Coverage decisions must reference and conform to federal, state (Ohio Administrative Code), or contractual requirements; in the event of a conflict, those governing requirements take precedence.

Use InterQual® as the primary utilization review criteria for home care; if InterQual® criteria are not available, UnitedHealthcare Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by Ohio Medicaid may be used.
All services must be prescribed by the treating practitioner and documented as skilled care provided in the member's residence when applicable.
Claims must include applicable procedure/service codes and documentation that supports medical necessity per InterQual LOC and Ohio rules.
Requests for unproven services or services with limits will be evaluated under OAC 5160-101 and plan/contract requirements.
When determining coverage, reference federal, state (OAC), or contractual requirements; those requirements govern in case of conflict.

Definitions and Key Terms

inv-20: InterQual LOC: Home Care Q & A — referenced clinical criteria set used to determine medical necessity

Referenced criteria setInterQual LOC: Home Care Q & A — Home Care Services, Adult and Pediatric (used to determine medical necessity)

inv-21: Skilled care services — Medically necessary services provided in the member's residence by licensed professionals

DefinitionSkilled care services are medically necessary services provided in the member's place of residence by licensed health care professionals.

ExamplesMay include medical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy.

Prescriber requirementServices must be prescribed by a treating practitioner or specialist (MD, DO, PA, or NP).

Background and Clinical Sources

This policy uses the InterQual Levels of Care (LOC) for Home Care as the primary clinical criteria to adjudicate medical necessity for home health services. InterQual guidance, together with applicable federal, state and contractual requirements, supports determinations about skilled care, visit frequency, and service appropriateness for home-based skilled nursing, therapy, infusion, and related services.