Home Health Services Clinical Coverage Criteria
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Defines medical necessity, authorization, and documentation requirements for home health services provided to Fallon Health members and describes program variations for Medicare Advantage, MassHealth, NaviCare, and PACE. Affects providers requesting prior authorization for home health services.
Fallon Health is delegating utilization management for home health services for all plan members, except PACE members, to Integrated Home Care Services effective July 1, 2025.
New specific Medicare and MassHealth variation sections were added to clarify that Medicare Advantage and MassHealth determinations follow respective regulations/guidelines.
Coverage and Medical Necessity Criteria
Medical necessity criteria
Home health services may be considered medically necessary when ALL of the following criteria are met:
All criteria must be supported in the member's medical record.
All criteria must be supported in the member's medical record.
All criteria must be supported in the member's medical record.
All criteria must be supported in the member's medical record.
All criteria must be supported in the member's medical record.
Medicare variation
Medicare Advantage variation
All criteria must be supported in the member's medical record.
MassHealth variation
MassHealth variation
All criteria must be supported in the member's medical record.
Home health services that fall outside the scope of this policy are not covered. Specifically, the policy excludes: home health services other than those described in this document, custodial care unless it is specifically covered under the member’s benefit plan, and services provided in the home solely for the member’s convenience. Coverage for any service referenced elsewhere in the policy is subject to the member’s specific benefit plan; when a plan’s Evidence of Coverage contains different provisions, those plan terms govern.
Services that do not meet the medical necessity criteria listed in this policy are considered not medically necessary. This includes care that is primarily custodial in nature (unless the member’s plan explicitly covers custodial care) and any services rendered for the member’s convenience rather than for a documented clinical need. Prior authorization and supporting clinical documentation should demonstrate that all required medical necessity elements are present; absent those elements, services may be denied.
Procedure and Revenue Codes
| G0156 | Services of home health/hospice aide in home health or hospice settings, 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 |
| G0493 | Skilled services of a registered nurse (RN) for observation and assessment of the patient's condition, each 15 minutes |
| T1502 | Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit |
| T1503 | Administration of medication, other than oral and/or injectable, by a health care agency/professional, per visit |
| 0421 | Physical Therapy Visit Charge |
| 0431 | Occupational Therapy Visit Charge |
| 0441 | Speech Therapy Language Pathology Visit Charge |
| 0550 | Skilled Nursing General Charge |
| 0551 | Skilled Nursing Visit Charge |
| 0552 | Skilled Nursing Hourly Charge |
| 0559 | Skilled Nursing Other Charge |
| 0561 | Home Health Medical Social Services Visit Charge |
| 0572 | Home Health Aide Hourly Charge |
| 0579 | Home Health Aide Other Charge |
Prior Authorization, Documentation, and Denial Risk
Prior authorization required for skilled home health services
Prior authorization (initial and renewal) is required for skilled nursing and therapy home health services for Fallon Health members; submit requests to Integrated Home Care Services (FAX 844-215-4265), except for PACE members. Prior authorization is not a guarantee of payment and remains subject to eligibility at time of service.
- Applies to initial and renewal authorizations for skilled nursing and therapy services.
- Send requests to Integrated Home Care Services at FAX 844-215-4265 per delegation effective 7/1/2025.
PACE prior authorization routed to PACE interdisciplinary team
For PACE members, prior authorization requests must continue to be submitted to the member's PACE interdisciplinary care team rather than to Integrated Home Care Services.
- PACE participants’ services must be authorized by their Interdisciplinary Team except for emergency and out-of-area urgently needed care.
Step therapy
Step therapy requirements are not specified in this policy.
Required documentation for prior authorization and recertification
Include diagnosis, functional level, and specific therapy needs, and attach supporting clinical documentation; recertification requires submission of the signed and dated plan of care for the prior certification period plus re-evaluation documentation by the appropriate discipline.
- Supporting clinical documentation: physician office visit and/or history & physical, hospital/SNF discharge summary.
- Plan of care must be developed by the home health agency and reviewed and signed by the physician or allowed practitioner at least every 60 days.
- Recertification: signed/dated prior plan of care and re-evaluation by RN, PT, OT, or ST.
Denial triggers — missing documentation or excluded services
Requests may be denied if supporting clinical documentation is missing, if there is no ordered plan of care signed/reviewed by a physician or allowed practitioner, or if the services are custodial, for convenience, or otherwise excluded.
- Missing physician office visit, H&P, or hospital/SNF discharge summary risks denial.
- Lack of a signed/reviewed plan of care or missing re-evaluation documentation for recertification may result in denial.
- Requests for custodial care or services provided for the member's convenience are excluded and may be denied.
Key Definitions
Background and Policy Scope
Home health services provide skilled clinical care and rehabilitation in the member’s residence, either following an inpatient stay or to prevent a hospital or facility admission. These services are intended for members who are homebound and who have a clinical need for part-time, intermittent skilled services delivered by disciplines such as registered nursing, physical therapy, occupational therapy, or speech therapy. Services must be ordered and provided under a physician-established plan of care, have a reasonable endpoint toward medical stability, and be those that can only be safely and effectively provided by or under the supervision of a licensed clinician.
Policy Changes and Revision History
Fallon Health delegated utilization management for home health services (all plan members except PACE) to Integrated Home Care Services and directed prior authorization requests to Integrated Home Care Services (FAX 844-215-4265).
Policy updated to include information about Fallon Health's partnership with Integrated Home Care Services effective 7/1/2025.
Utilization Management Committee annual review approved the policy with no changes to coverage criteria and added new sections for Medicare and MassHealth variation.
Added additional non-skilled coverage for MassHealth and added codes.
Technology Assessment Committee approved the policy as a new policy (origination).
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