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
POLICY UPDATE CHANGES
Supporting Information Updated References section to reflect the most current information; Archived previous policy version CS137.W.
InterQual LOC referencedclinical criteria source
20+ codesprocedure codes listed
multiplehome infusion codes
listedstate exceptions
<4 hrs/daytypical duration
07/01/2026revision date
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.
Intermittent and part-time (typically provided for less than 4 hours per day).
Exceptions to intermittent care may be made when the need for more care is finite and predictable.
Services must require clinical training to be delivered safely and effectively to qualify as skilled care (examples: skilled nursing, skilled rehabilitation, skilled teaching).
Therapy received in the home from a home health agency is covered under the home health benefit; therapy received in the home from an independent therapist is covered under outpatient rehabilitation benefit.
Medical supplies and medications used in conjunction with a home health visit (e.g., catheters, irrigation devices, surgical dressings, syringes) are included as part of the visit.
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)
S9376 thresholdS9376: Home infusion hydration therapy — more than 2 liters but no more than 3 liters per day (per diem).
S9377 thresholdS9377: Home infusion hydration therapy — more than 3 liters per day (per diem).
S9374–S9375 contextS9374 and S9375 are per diem home infusion codes for pharmacy services, care coordination, and supplies; do not mix with hydration codes on daily volume scales where restricted.
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.
PurposeDesigned to restore or maintain maximal function and health and to prevent or postpone hospitalization by providing intermittent care in lieu of outpatient or facility services.
Delivery patternServices are provided intermittently (typically) and in the member's residence; therapy delivered by a home health agency is covered under the home health benefit.
Skilled care services — licensed, medically necessary
DefinitionSkilled care services are medically necessary services provided in the member's place of residence by licensed health care professionals.
Examples of servicesMay include medical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, and therapy services (physical, speech, occupational).
Provider requirementMust be delivered by licensed professionals and require clinical training to be provided safely and effectively in the home setting.
Custodial care services — non‑medical ADL and homemaking support
DefinitionCustodial care services are non‑medical services that assist with personal care and activities of daily living, housekeeping, cooking, or laundry, or supervision of self‑administered medication.
Provider levelCan reasonably and safely be provided by non‑licensed caregivers; not considered skilled medical care.
Coverage distinctionCustodial care is excluded from skilled home health benefit when services are solely for comfort, convenience, or routine personal assistance rather than medically necessary skilled interventions.
Policy Changes and References
2026-07-01administrativeLatest
Supporting Information: updated References section and previous policy version CS137.W archived.
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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