CurrentColorado Rocky Mountain Health PlansPolicy 2025R9067A

Reimbursement for home health services billed on CMS 1500 / UB-04 during inpatient stay

Govern reimbursement when home health services (POS 12 or specific UB-04 bill types) overlap with an inpatient stay for UnitedHealthcare Medicare Advantage plans; affects claims submitted by participating and non‑participating providers for Medicare Advantage products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for home health services billed on CMS 1500 / UB-04 during inpatient stay

Policy CodePolicy 2025R9067A

Change TypeNew policyanniversary review

Effective Date

Next Review Date

Key ActionSubmit accurate claims on CMS 1500 or UB-04 (or electronic equivalent).

SourceLink

POLICY UPDATE CHANGES

New Policy Implemented by UnitedHealthcare Medicare Advantage on 10/1/2024.

Policy version change anniversary review dated 7/1/2025.

321-329, 341-345, 347-349UB-04 bill types that indicate home health services

POS 12Place of Service code indicating home health on CMS-1500

Admission & dischargeInpatient boundary exceptions

Medicare AdvantageProduct applicability

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Home health during inpatient stay

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- CMS-1500 with Place of Service (POS) 12 (indicating services provided in a private residence).
- Or UB-04 type of bill 321-329, 341-345, or 347-349.
ALL of the following
- Overlap rule: If both home health (POS 12 or specified UB-04 types) and inpatient care are billed for the same dates, UnitedHealthcare will reimburse inpatient care only and home health services for those overlapping dates are not eligible for reimbursement.
- Exceptions: Dates of admission and discharge are exceptions: home health services provided on those dates may still be eligible for reimbursement.
ALL of the following
- Applies to claims submitted by both participating and non-participating providers for benefit plans that include out-of-network coverage.
ALL of the following
- Services may include part-time or intermittent skilled nursing, physical therapy, occupational therapy, speech-language pathology, part-time or intermittent home health aide services, medical social services, Durable Medical Equipment (DME), and medical supplies.
ALL of the following
- Home health services must be submitted with POS 12 on CMS-1500 or with UB-04 type of bill 321-329, 341-345, or 347-349 to indicate services were provided in a private residence (not a hospital or other facility).

Claim form indicators and overlap rule

Home health claim form indicatorsmixed

POS 12	Place of Service code indicating home health services on CMS-1500
UB-04 types 321-329	Home health billing types
UB-04 types 341-345	Home health billing types
UB-04 types 347-349	Home health billing types

Overlap rule — home health vs inpatient

Overlap rule summaryIf home health services (POS 12 on CMS-1500 or UB-04 type of bill 321-329, 341-345, or 347-349) and inpatient care are billed for the same dates of service, UnitedHealthcare will reimburse the inpatient care only; home health services for those overlapping dates are not eligible for reimbursement.

Exception — admission and discharge datesDates of admission and discharge are exceptions; home health services provided on those dates may still be eligible for reimbursement.

Required claim indicators for home healthHome health services must be submitted with POS 12 on a CMS-1500 or with UB-04 type of bill 321-329, 341-345, or 347-349 to indicate services were provided in a private residence.

Scope of applicationThis reimbursement rule aligns with CMS guidance and applies to UnitedHealthcare Medicare Advantage reimbursement for overlapping home health and inpatient billing.

Claims submission and prior authorization note

Documentation Required

Claims must be accurately submitted on CMS-1500 or UB-04 (or electronic equivalent)

Submit accurate claims on the appropriate form (CMS-1500 or UB-04) or the electronic equivalent. This policy applies to all Medicare Advantage products and for network provider services reported using the UB-04 and CMS 1500 form or its electronic equivalent.

Ensure claims are submitted with the codes that correctly describe the health care services provided.
Use CMS-1500 for professional claims (including POS 12 when reporting home health) or UB-04 (CMS 1450) for facility billing as applicable.

Key definitions

Durable Medical Equipment (DME) definition

DefinitionDurable Medical Equipment (DME): Medical equipment which can withstand repeated use, is not disposable, is used to serve a medical purpose, is generally not useful to a person in the absence of sickness or injury, and is appropriate for use in the home.

Characteristic — reuseCan withstand repeated use (not single-use or disposable).

Characteristic — medical purposeUsed to serve a medical purpose and generally not useful without sickness or injury.

Characteristic — home useAppropriate for use in the home setting.

Place of Service (POS) definitions and usage

DefinitionPlace of Service (POS): A two-digit code used on health care professional claims to indicate the setting in which a service was provided.

Home health POS codePOS 12 indicates home health services on a CMS-1500 claim form.

Use on professional claimsPOS codes are reported on CMS-1500 (professional) claims to specify the service location (e.g., private residence).