ModifiedFallon Community Health Plan IncPolicy N/A

Home Health Care Payment Policy

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Coverage, medical necessity, prior authorization, billing, coding, reimbursement, and documentation requirements for home health care services furnished in the home setting across Fallon Medicare Plus, MassHealth ACO, NaviCare HMO SNP, Summit ElderCare PACE, Fallon Health Weinberg PACE, and Community Care.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyHome Health Care Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for home health care and submit requests to Integrated Home Care Services unless the member is enrolled in Summit ElderCare PACE or Fallon Health Weinberg PACE.

SourceLink

POLICY UPDATE CHANGES

Removed outdated COVID-19-related policy updates.

Added Modifier EY billing guidance for MassHealth ACO and NaviCare members.

Added Universal Postpartum Home Visiting Services billing guidance for Community Care members.

Added T1019 billing guidance for Fallon Health Weinberg personal care aide services.

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ModifiedFallon Community Health Plan IncPolicy N/A

Home Health Care Payment Policy

Customize your policy alerts

Sign up for all fallon_community_health_plan_inc policy alerts

Know when fallon_community_health_plan_inc releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyHome Health Care Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for home health care and submit requests to Integrated Home Care Services unless the member is enrolled in Summit ElderCare PACE or Fallon Health Weinberg PACE.

SourceLink

POLICY UPDATE CHANGES

Removed outdated COVID-19-related policy updates.

Added Modifier EY billing guidance for MassHealth ACO and NaviCare members.

Added Universal Postpartum Home Visiting Services billing guidance for Community Care members.

Added T1019 billing guidance for Fallon Health Weinberg personal care aide services.

RequiredPrior authorization

2 ADLsMinimum ADLs for certain aide services

60 daysRN aide supervision interval

8 weeksFirst postpartum home visit

12 monthsModifier EY resubmission period

15 minutesHCPCS service unit

Coverage Criteria

General home health coverage

Covered when all applicable criteria are met.

Core home health criteria: Services are ordered by a licensed physician (MD, DO, or DPM), and the physician signs a plan of care certifying that the home health services are medically necessary.

Core home health criteria: The member is under a plan of treatment established and periodically reviewed by a licensed physician.

Product-specific homebound rule: The member is homebound and unable to leave the home without a taxing effort for Community Care and Medicare Advantage products; or the member is enrolled in a product with MassHealth enrollment, including dual-enrolled NaviCare and Summit ElderCare programs, for which there is no homebound requirement.

Qualifying service need: The member has a clinical need for part-time, intermittent skilled nursing, physical therapy, occupational therapy, or speech therapy; or the member qualifies under an explicit product-specific home health aide exception.

Medical social work and home health aide services generally require a concurrent need for one of the listed skilled services, subject to stated exceptions.

Service duration: There is a medically necessary endpoint to the services.

Face-to-face certification: The certifying physician documents that the physician or an allowed non-physician practitioner had a face-to-face encounter with the patient.

MassHealth ACO and NaviCare non-skilled home health aide services

Covered for MassHealth ACO and NaviCare members when all applicable criteria are met.

Home health aide without concurrent skilled need: The member requires medically necessary hands-on assistance throughout the task or until completion with at least two activities of daily living: bathing, grooming, dressing, toileting or continence, transferring or ambulation, or eating.At least 2 ADLs

The physician must order the frequency and duration, and the services must be included in the member's plan of care.

Personal care purpose: The services are medically necessary to provide personal care to the member, maintain the member's health, or facilitate treatment of the member's injury or illness.

Authorization and supervision: Authorization is obtained when required, and a registered nurse makes an on-site visit no less frequently than every 60 days to observe and assess each home health aide while the aide is performing care.RN visit no less frequently than every 60 days

Summit ElderCare home health aide exception

Covered for Summit ElderCare members when applicable requirements are met.

Summit ElderCare home health aide exception: The member has a medical need for home health aide assistance with personal care; a concurrent skilled service need is not required for Summit ElderCare members.

Physician ordering, a physician-signed plan of care, medical necessity, authorization when required, and other applicable requirements remain necessary.

Other services furnished by home health agencies

May be reimbursed when all applicable conditions are met.

Outpatient therapy furnished by a home health agency: The home health agency is permitted by its provider contract with the Plan to furnish outpatient physical therapy, outpatient occupational therapy, or outpatient speech-language pathology services to a Medicare member who is not homebound and is not otherwise receiving services under a home health plan of care.

Services must be billed with applicable therapy procedure codes, therapy revenue codes, therapy modifiers, and therapy assistant modifiers.

Universal postpartum home visiting services

Covered for Community Care members under the postpartum criteria.

First universal postpartum home visit: The service is an evidence-based, voluntary home or community-based visit for a birthing person or caregiver with a newborn, including services such as screening for unmet health needs, addressing maternal and infant nutritional needs, and providing emotional health supports.First visit within 8 weeks postpartum

The visit must occur at the patient's home or a mutually agreed-upon location. The first visit does not require prior authorization.

Additional postpartum visits: An additional postpartum home visit is medically necessary and has the required prior authorization.

Additional visits must be billed with revenue code 0551, 0552, or 0559 and ICD-10-CM diagnosis code Z39.2.

Coding and Billing Codes

Home health and hospice HCPCS codesHCPCS

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist 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.
G0158	Services performed by a qualified occupational therapist assistant 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.
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.

1–10 of 12

1/2

Home health revenue codesRevenue

0550	High-tech RN visit.
0551	RN skilled visit.
0552	RN, hourly.
0559	RN, other.
0582	Licensed Practical Nurse (LPN).
0589	LPN visit.
0572	Certified HH aide hourly.
0579	Certified HH aide, other.
0421	PT visit.
0431	OT visit.

1–10 of 15

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MassHealth ACO, NaviCare, and Summit ElderCare PACE codesHCPCS

T1502	Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit; with revenue code 0590.
T1503	Administration of medication, other than oral and/or injectable, by a health care agency/professional, per visit; with revenue code 0590.

Fallon Health Weinberg PACE codeHCPCS

T1019

Services of personal care aide in home health settings, each 15 minutes.

Universal postpartum home visiting codesmixedCovered

99501	Home visit for postpartum care.
Z39.2	Encounter for routine postpartum follow-up.

Modifier EYModifierNot Covered

EY	No physician or other licensed health care provider order for this item or service.

Outpatient therapy billing codesmixed

042X	Therapy revenue codes.
043X	Therapy revenue codes.
044X	Therapy revenue codes.
GN	Therapy modifier.
GO	Therapy modifier.
GP	Therapy modifier.
CQ	Therapy assistant modifier.
CO	Therapy assistant modifier.

Postpartum home visit revenue codesRevenueCovered

0551	RN skilled visit revenue code for postpartum home visits.
0552	RN hourly revenue code for postpartum home visits.
0559	RN other revenue code for postpartum home visits.

Ordering/referring provider qualifiersModifier

DN	Referring provider qualifier.
DK	Ordering provider qualifier.

Ordering/referring provider qualifiersModifier

DN	Referring Provider qualifier
DK	Ordering Provider qualifier

Billing/coding guideline updateHCPCS

T1019

Fallon Health Weinberg personal care aide services

Modifier billing guideline updateModifier

EY	Modifier EY billing guidance for MassHealth ACO and NaviCare members

Plan-specific billing codesmixed

HIPPS

HIPPS codes submitted on claims for Fallon Senior Plan members

Authorization, Documentation, and Claim Requirements

Prior Authorization

Home Health Prior Authorization

Home health care requires prior authorization. Effective July 1, 2025, submit requests for all members except Summit ElderCare PACE and Fallon Health Weinberg PACE members to Integrated Home Care Services (IHCS) by fax at 844-215-4265.

Summit ElderCare PACE and Fallon Health Weinberg PACE requests continue to be submitted to the member’s interdisciplinary care team.

Prior Authorization

PACE Authorization Pathway

PACE members receive care authorized by their interdisciplinary team. Except for emergency care and out-of-area urgently needed care, submit all care and services for Summit ElderCare PACE and Fallon Health Weinberg PACE members to the member’s interdisciplinary team.

PACE authorization remains with the interdisciplinary care team, including after the July 1, 2025 IHCS routing change for other members.

Unsupported block type: prior_auth kesimlija

Policy Background

Home health care consists of medically necessary services furnished in the member’s home by a Medicare-certified home health agency. Covered services may include skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work, and home health aide services. Services are considered skilled when they can be safely and effectively provided only by, or under the supervision of, a licensed clinician. This policy applies to services rendered in the home setting.

Definitions and Guidelines

Skilled Home Health Care Guidelines

Service settingHome health care services are provided to members in their home by Medicare-certified home health care agencies.

Covered service categoriesSkilled nursing, physical therapy, occupational therapy, speech therapy, medical social work, and home health aide services.

Definition of skilled servicesServices are considered skilled when they can only be safely and effectively provided by and/or under the supervision of a licensed clinician.

Ordering requirementHome health care services must be ordered by a licensed physician.

Eligibility standardThe member must meet Medicare home health care criteria to qualify for these services.

Activities of Daily Living

Policy Summary

PayerFallon Community Health Plan Inc

PolicyHome Health Care Payment Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for home health care and submit requests to Integrated Home Care Services unless the member is enrolled in Summit ElderCare PACE or Fallon Health Weinberg PACE.

SourceLink

On This Page

Applies when home health aide services are not provided pursuant to a skilled nursing or therapy need.

Prior Authorization

MassHealth and PACE Code Authorization

Plan prior authorization is required for the listed MassHealth ACO, NaviCare, and Summit ElderCare PACE code groups. Route PACE requests to the member’s interdisciplinary team.

G0299 — direct skilled nursing services by an RN, each 15 minutes.
G0300 — direct skilled nursing services by an LPN, each 15 minutes.
G0493, G0156 with modifier UD, and T1502 are also listed for applicable MassHealth ACO, NaviCare, and Summit ElderCare PACE services.

Prior Authorization

Weinberg PACE Personal Care Aide Authorization

Plan prior authorization is required for Weinberg PACE personal care aide services billed with HCPCS T1019. Submit requests to the member’s interdisciplinary team.

T1019 — personal care aide services in home health settings, each 15 minutes.

Prior Authorization

Postpartum Home Visit Authorization

The first universal postpartum home visit for a Community Care member, occurring within 8 weeks postpartum, does not require prior authorization. Additional postpartum visits may be covered when medically necessary but require prior authorization.

For additional visits effective July 1, 2025, submit home health authorization requests to IHCS by fax at 844-215-4265.
First-visit billing: revenue code 0551, 0552, or 0559; CPT 99501; ICD-10-CM Z39.2.
Additional-visit billing: revenue code 0551, 0552, or 0559 and ICD-10-CM Z39.2.

Documentation Required

Core Certification and Plan-of-Care Records

Before providing covered home health services, obtain a licensed physician’s order and a physician-signed plan of care certifying medical necessity. Keep documentation that the member is under a physician-established and periodically reviewed treatment plan, including the certifying physician’s documentation of a face-to-face encounter by the physician or an allowed non-physician practitioner.

The order must be from an MD, DO, or DPM.
The plan of care must support the services and be periodically reviewed by a licensed physician.
Maintain records supporting medical necessity and the face-to-face encounter.

Documentation Required

Non-Skilled Aide Eligibility

For MassHealth ACO and NaviCare members receiving home health aide services without a concurrent skilled nursing or therapy need, document hands-on assistance throughout the task or until completion with at least two activities of daily living (ADLs).

Qualifying ADLs are bathing, grooming, dressing, toileting/continence, transferring/ambulation, and eating.
Summit ElderCare members are not required to have a skilled-service need to qualify for a personal-care home health aide.

Documentation Required

RN Aide Supervision

When aide services are provided without a skilled nursing or therapy need, a registered nurse must make an on-site visit to observe and assess each aide while performing care.

The RN visit must occur at least every 60 days.

Unsupported block type: billing_rule

Billing Rule

Ordering/Referring Provider Claim Data

Report the ordering provider’s name, qualifier, and NPI in the required CMS-1500 or electronic claim fields. Do not report information in CMS-1500 Item 17a.

CMS-1500: report the provider name in Item 17, qualifier to the left of the dotted line, and NPI in Item 17b.
837P: report the provider in loop 2420E, including NM101, NM103-NM105, and NM109 for the NPI.
Item 17a formerly held the UPIN and must remain blank.

Documentation Required

Medical-Record Support for Billed Services

Maintain medical records that support the services billed and demonstrate compliance with the policy’s documentation and billing requirements. The Plan verifies that billed charges are appropriately documented.

Payments are subject to post-payment audits and retraction of overpayments.
Provider contract terms and individual member benefit plans may also apply.

Denial Risk

Missing Physician Order or Signed Plan of Care

Claims may be denied when the required physician order or signed plan of care is missing. Do not bill services without an established, signed plan of care applicable to the dates of service.

A physician must order the services and sign the plan of care certifying medical necessity.
Claims submitted with modifier EY are denied; resubmission without EY is permitted within 12 months only after securing a signed plan of care applicable to the specific dates of service.

Denial Risk

No Qualifying Skilled Need

Except for applicable product-specific exceptions, the member must have a clinical need for part-time, intermittent skilled services from at least one qualifying discipline before medical social worker or personal-care home health aide services qualify.

Qualifying skilled disciplines are skilled nursing, physical therapy, occupational therapy, and speech therapy.
Summit ElderCare members may qualify for a personal-care home health aide without a skilled-service need.
MassHealth ACO and NaviCare members may qualify without a concurrent skilled need when the hands-on, two-ADL requirements are met.

Denial Risk

Homebound Requirement

Community Care and Medicare Advantage members must be homebound to receive covered home health services. The member must be unable to leave home without a taxing effort.

There is no homebound requirement for products with MassHealth enrollment, including the dual-enrolled NaviCare and Summit ElderCare programs.

Denial Risk

Modifier EY Claim Denial

A claim billed with modifier EY for MassHealth ACO or NaviCare home health services is denied and will not be reimbursed.

The provider has 12 months from the date of service to resubmit without modifier EY after obtaining a signed plan of care applicable to the claim’s dates of service.

Denial Risk

Recoupment for Absent Plan of Care

Home health providers who submit claims without an established, signed plan of care may be subject to recoupment by the Plan.

Secure and retain the signed plan of care before billing whenever possible.

Prior Authorization

Unlisted Code Authorization

Use industry-standard procedure and revenue codes valid on the date of service. If no specific industry-standard code is available, obtain Plan prior authorization before billing an unlisted code.

Claims must include a corresponding HCPCS code even when the provider contract reimburses based on a revenue code.
Use revenue codes stated in the provider contract.

Denial Risk

No Medically Necessary Endpoint

Covered home health services must have an endpoint based on medical necessity. Document the expected endpoint and reassess ongoing services rather than continuing them indefinitely.

The member must remain under a physician-established and periodically reviewed plan of treatment.

Denial Risk

Missing Ordering/Referring Provider Information

Claims resulting from an order or referral may be denied or delayed when the required ordering or referring provider information is missing or invalid.

Include the provider’s name, appropriate DN or DK qualifier, and valid NPI on the claim.

Denial Risk

Unsupported or Improperly Documented Charges

Charges must be supported by appropriately documented medical records and billed in accordance with the policy, applicable contract, and member benefit plan. Unsupported or improperly documented charges may be identified through post-payment review.

The Plan may audit claims and retract overpayments.

BathingQualifying activity of daily living.

GroomingQualifying activity of daily living.

DressingQualifying activity of daily living.

Toileting/continenceQualifying activity of daily living.

Transferring/ambulationQualifying activity of daily living.

EatingQualifying activity of daily living.

Coverage thresholdFor specified MassHealth ACO and NaviCare home health aide services without a concurrent skilled need, the member must require hands-on assistance throughout the task or until completion with at least 2 activities of daily living.