CurrentColorado Rocky Mountain Health PlansPolicy CS137.X

Home Health, Skilled, and Custodial Care Services

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Defines Colorado Rocky Mountain Health Plans' coverage framework, applicable codes, definitions, and use of InterQual LOC criteria for home health, skilled, and custodial care services; affects providers and claim adjudicators for members covered by this policy (state exceptions listed).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHome Health, Skilled, and Custodial Care Services

Policy CodePolicy CS137.X

Change TypeAdministrative — references updatedprior version archived

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review Date

Key ActionRefer to InterQual LOC: Home Care Q&A for medical necessity determinations when requesting authorization.

SourceLink

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CurrentColorado Rocky Mountain Health PlansPolicy CS137.X

Home Health, Skilled, and Custodial Care Services

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Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHome Health, Skilled, and Custodial Care Services

Policy CodePolicy CS137.X

Change TypeAdministrative — references updatedprior version archived

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review Date

Key ActionRefer to InterQual LOC: Home Care Q&A for medical necessity determinations when requesting authorization.

SourceLink

Coverage and Medical Necessity Criteria

Medical necessity and applicability criteria

Coverage is determined by medical necessity using InterQual Level of Care (LOC) Home Care criteria and by applicable federal, state, and contractual definitions; services are limited to the member's place of residence as defined below.

Medical necessity determinations must reference InterQual® LOC: Home Care Q&A (Home Care Services, Adult and Pediatric).

Refer to InterQual criteria for specific level-of-care rules and clinical indicators.

ALL of the following

Service must occur in a non-institutionalized setting in which normal life activities take place.
Does not include settings where payment is, or could be, made under Medicaid for inpatient services that include room and board (for example: hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities), except as allowed by CFR § 440.70.
Check federal, state, and contractual requirements which supersede these definitions when applicable.

Coverage criteria for home health skilled services

Covered when ALL of the following general requirements are met:

Ordered and directed by a treating practitioner or specialist (MD, DO, PA, or NP).

Delivered or supervised by a licensed professional in order to obtain a specified medical outcome.

Not custodial in nature (services must be skilled, not solely for activities of daily living, housekeeping, or supervision).

Not provided for the comfort or convenience of the member or the member's family.

Provided in the home in lieu of skilled care in another setting (e.g., nursing facility, acute inpatient rehabilitation, or hospital).

Clinically appropriate and no more costly than an alternative health service.

Applicable Procedure and Billing Codes

Selected CPT home visit and infusion codesCPT

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.
99503	Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
99504	Home visit for mechanical ventilation care.
99505	Home visit for stoma care and maintenance including colostomy and cystostomy.
99506	Home visit for intramuscular injections.
99507	Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
99511	Home visit for fecal impaction management and enema administration.
99601	Home infusion/specialty drug administration, per visit (up to 2 hours).

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Selected HCPCS/G-codesHCPCS

G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0069	Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0070	Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0088	Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0089	Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0152	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.

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Home infusion and per diem S-codesHCPCS

S5035	Home infusion therapy, routine service of infusion device (e.g., pump maintenance).
S5036	Home infusion therapy, repair of infusion device (e.g., pump repair).
S5108	Home care training to home care client, per 15 minutes.
S5109	Home care training to home care client, per session.
S5110	Home care training, family; per 15 minutes.
S5111	Home care training, family; per session.
S5115	Home care training, nonfamily; per 15 minutes.
S5116	Home care training, nonfamily; per session.
S5180	Home health respiratory therapy, initial evaluation.
S5181	Home health respiratory therapy, NOS, per diem.

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Applicable HCPCS / T-codes for home health and infusion servicesHCPCSCovered

S9374	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (do not use with hydration therapy codes S9374 - S9377 using daily volume scales).
S9375	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9376	Home infusion therapy, hydration therapy; more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9377	Home infusion therapy, hydration therapy; more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9379	Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9474	Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem.
S9490	Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9497	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
S9498	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.

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Time increment billing — 15‑minute units

Billing incrementMany professional home health and infusion services are billed in 15-minute increments per code descriptors (examples include G0152–G0162 and skilled nursing codes specified as 'each 15 minutes').

Applicable codes (examples)G0152, G0153, G0155–G0162 and other HCPCS codes specify units 'each 15 minutes' for therapy and skilled services.

Use with visit-based suppliesTime-based billing applies to professional visit and therapy services; supplies and drugs are coded separately as indicated in code descriptors.

Documentation requirementClaimed 15-minute units must be supported by clinical documentation of the time and services provided during the visit.

Hydration volume thresholds (S9376 / S9377)

Provider Responsibilities and Policy Use

Prior Authorization

Use InterQual LOC: Home Care Q&A for medical necessity

Medical necessity clinical coverage criteria for home health and skilled care services are determined using the InterQual® LOC: Home Care Q&A (Home Care Services, Adult and Home Care Services, Pediatric). Providers should refer to InterQual criteria when requesting authorization or documenting medical necessity.

Documentation Required

Confirm benefit terms and third‑party tool use before applying policy

Before relying on this policy, check applicable federal, state, or contractual benefit requirements because those terms govern in the event of a conflict; UnitedHealthcare may use third-party tools (for example, InterQual) to assist in administering benefits.

Verify federal, state, and member contract terms prior to authorization or billing.
Confirm whether third-party decision tools (e.g., InterQual) will be used in benefit determinations.

Key Definitions

Place of Residence for Home Health Services

DefinitionPlace of Residence for Home Health Services: any non-institutionalized setting in which normal life activities take place.

ExclusionsDoes not include settings where payment is, or could be, made under Medicaid for inpatient services that include room and board (e.g., hospital, nursing facility, or ICF/IID), except limited exceptions per CFR § 440.70.

Regulatory referenceReferenced federal regulation: CFR § 440.70 applies to exclusions and limited exceptions for institutional settings.

Home health care services — short‑term, in‑residence

DefinitionHome health care services are short-term services prescribed by a treating practitioner (MD, DO, PA, or NP) and delivered in a member's residence to help recovery after illness, injury, hospital stay, or surgery or to manage a chronic condition.

Purpose

Policy Changes and References

2026-07-01administrativeLatest

Supporting Information: updated References section and previous policy version CS137.W archived.