ModifiedFallon Community Health Plan IncPolicy N/A

Day Habilitation

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This policy governs coverage, prior authorization, medical necessity, documentation, service-level determination, and exclusions for Day Habilitation services for eligible Fallon Health members with intellectual or developmental disabilities. It applies to NaviCare HMO SNP and PACE products and directs providers on authorization and billing requirements.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyDay Habilitation

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 202757d

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionBeginning January 1, 2027, NaviCare providers must submit complete Day Habilitation authorization requests directly to Fallon Health.

SourceLink

POLICY UPDATE CHANGES

The policy clarified NaviCare and PACE authorization pathways, authorization types, documentation, provider transfer, reauthorization, service nonduplication, and coding requirements.

The policy was revised to align with the Day Habilitation Payment Policy and clarify NaviCare and PACE authorization pathways, authorization types, documentation, provider transfer, reauthorization, nonduplication, and coding requirements.

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ModifiedFallon Community Health Plan IncPolicy N/A

Day Habilitation

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Sign up for all fallon_community_health_plan_inc policy alerts

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Policy Summary

PayerFallon Community Health Plan Inc

PolicyDay Habilitation

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 202757d

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionBeginning January 1, 2027, NaviCare providers must submit complete Day Habilitation authorization requests directly to Fallon Health.

SourceLink

POLICY UPDATE CHANGES

The policy clarified NaviCare and PACE authorization pathways, authorization types, documentation, provider transfer, reauthorization, service nonduplication, and coding requirements.

Before services begin

Prior authorization timing requirement

Up to 2 yearsMaximum authorization period

Levels 1-4Day habilitation service levels

7Explicit exclusion categories or circumstances

3Medical necessity frameworks

Coverage Criteria

Medical necessity

Day Habilitation is medically necessary when all of the following are met:

Medical necessity criteria: The member has a documented intellectual or developmental disability; requires Day Habilitation to acquire, maintain, or improve functional skills or independence; the Service Needs Assessment (SNA), Leveling Tool, Day Habilitation Service Plan (DHSP), and supporting clinical records establish the appropriate service level; services are coordinated with other programs and do not duplicate another covered service; and any additional requirements applicable to nursing-facility residence are met.

For members receiving hospice services, documentation must demonstrate coordination of services and that requested Day Habilitation services are not duplicative of services covered by hospice.

Level of need determination

Fallon Health determines the appropriate service level based on all of the following:

Service-level determination: The member's medical and behavioral health needs, the Service Needs Assessment (SNA), a completed Day Habilitation Leveling Tool, and, for a member residing in a nursing facility, the applicable Level II PASRR documentation are used to determine the appropriate service level.Levels 1 through 4

The Leveling Tool determines the appropriate service level and reimbursement rate.

Program-specific medical necessity framework

Medical necessity determinations follow the applicable program-specific authority:

Applicable medical necessity authority: For Medicare Advantage members, applicable CMS national coverage determinations, local coverage determinations of Medicare Contractors with jurisdiction for claims in the Plan's service area, and Medicare statutes and regulations apply; for MassHealth members, MassHealth Medical Necessity Guidelines apply, or, when MassHealth has not published applicable guidelines, Fallon Health may create clinical coverage criteria consistent with 130 CMR 450.204; for NaviCare members, Medicare authorities apply first, followed by MassHealth Medical Necessity Guidelines when Medicare authorities do not establish criteria or the member does not meet the applicable Medicare criteria.

PACE authorization requirement

PACE services must be authorized by the interdisciplinary team except for specified emergency circumstances.

PACE authorization: All care and services provided to PACE plan members must be authorized by the member's interdisciplinary team.

The exceptions are emergency care and out-of-area urgently needed care. PACE also provides Medicare- and Medicaid-covered care and services authorized by the interdisciplinary team, as well as additional medically necessary care and services not covered by Medicare and Medicaid.

Day Habilitation is not covered when the service is vocational, prevocational, employment-related, provided in a sheltered workshop, or academic-education service.

Day Habilitation is not covered for members residing in an ICF/IID.

Day Habilitation is not covered when services are provided without prior authorization.

Day Habilitation is not covered for canceled sessions or undocumented absences.

Day Habilitation is not covered when services are furnished during an inpatient stay, except as permitted on the admission or discharge date.

Day Habilitation is not covered when services duplicate hospice, nursing-facility, vocational, educational, or other covered services.

Day Habilitation is not covered when the program cannot safely or appropriately furnish the services.

Coverage is subject to the member’s particular benefit plan, which may include service-specific exclusions or benefit limitations regardless of medical necessity. If the policy conflicts with the member’s benefit plan, the benefit plan governs; consult the applicable Evidence of Coverage.

Day Habilitation Service Levels

Day Habilitation Levels 1-4

Day Habilitation service levels are assigned from Level 1 through Level 4 using the member's assessed support needs.

Levels 1 through 4: The appropriate Day Habilitation level must be determined from the member's medical and behavioral health needs, current Service Needs Assessment (SNA), and completed Day Habilitation Leveling Tool; for a member residing in a nursing facility, applicable Level II PASRR documentation must also be considered.Levels 1 through 4

The Leveling Tool determines the appropriate service level and reimbursement rate. The policy does not provide separate clinical criteria for each individual level.

CPT and HCPCS Coding

CPT/HCPCS Codes — per diem and half per diemHCPCS

S5102-U1	Day care services, adult, per diem (day habilitation, community based, Level 1
S5102-U2	Day care services, adult, per diem, intermediate level of care (day habilitation, community based, Level 2)
S5102-U3	Day care services, adult, per diem, complex/high tech level of care (day habilitation, community based, Level 3)
S5102-U4	Day care services, adult, per diem, complex/high tech level of care (day habilitation, community based or nursing facility resident, Level 4)
S5101-U1	Day care services, adult, half per diem (day habilitation, community based, Level 1
S5101-U2	Day care services, adult, half per diem, intermediate level of care (day habilitation, community based, Level 2)

CPT/HCPCS Codes — quarter per diem and transportationHCPCS

S5101-U3	Day care services, adult, half per diem, complex/high tech level of care (day habilitation, community based, Level 3)
S5101-U4	Day care services, adult, half per diem, complex/high tech level of care (day habilitation, community based or nursing facility resident, Level 4)
S5100-U1	Day care services, adult, quarter per diem (day habilitation, community based, Level 1)
S5100-U2	Day care services, adult, quarter per diem, intermediate level of care (day habilitation, Level 2)
S5100-U3	Day care services, adult, quarter per diem, complex/high tech level of care (day habilitation, community based, Level 3)
S5100-U4	Day care services, adult, quarter per diem, complex/high tech level of care (day habilitation, community based or nursing facility resident, Level 4)
T2003	Nonemergency transportation; non-wheelchair transportation; encounter/trip. Use for transportation furnished on a single date or on consecutive dates. All transportation services must be billed as one-way.
T2003-U6	Nonemergency transportation; wheelchair transportation; encounter/trip. Use for transportation furnished on a single date or on consecutive dates; round trips should be billed as two one-way trips.
T2003-U7	Nonemergency transportation; monitor transportation; encounter/trip. Use for transportation furnished on a single date or on consecutive dates; round trips should be billed as two one-way trips.

Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Obtain prior authorization before services begin and before the current authorization expires. Authorization may be approved for up to two years based on medical necessity and the assessed service level.

Submit and obtain approval before billing for services.
Authorization duration may be up to two years when supported by medical necessity and service-level assessment.

Prior Authorization

Provider Transfer Authorization

When a member changes Day Habilitation providers, the new provider must submit the current SNA and Day Habilitation Leveling Tool and obtain authorization before billing.

Submit any required supporting documentation with the transfer request.
Do not bill under the new provider until authorization is obtained.

Unsupported block type: prior_auth

Day Habilitation Overview

Day Habilitation is a structured, community-based service for members with intellectual or developmental disabilities who need support to acquire, maintain, or improve functional skills and independence. Services may include nursing oversight, developmental-skills training, therapy, behavioral support, and assistance with activities of daily living. A customized service plan and service-level assessment guide the goals and intensity of care.

Key Terms

Day Habilitation Service Plan (DHSP)

DefinitionA written care plan developed for each member that includes realistic, measurable goals.

ContentPrescribes a customized set of activities and therapies.

PurposeAims to improve or maintain the member's physical, cognitive, emotional, and occupational capabilities.

Developmental Disability (DD)

DefinitionA severe, chronic condition other than mental illness.

OnsetBegins before age 22.

Duration

Policy Summary

PayerFallon Community Health Plan Inc

PolicyDay Habilitation

Policy CodePolicy N/A

Change TypeModified

Effective DateJan 1, 202757d

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionBeginning January 1, 2027, NaviCare providers must submit complete Day Habilitation authorization requests directly to Fallon Health.

SourceLink

On This Page

Documentation Required

Change in Condition or Service Level

After a significant change in the member’s condition or service level, obtain an updated assessment and submit updated authorization documentation.

Reassess the member when the condition or requested level changes materially.
Support the revised service level with current clinical documentation.

Note

Medicare Advantage Medical Necessity Pathway

For Medicare Advantage members, apply CMS national coverage determinations, applicable local coverage determinations, and relevant Medicare statutes and regulations when making medical necessity determinations. Fallon may apply internal criteria when coverage is not fully established under the applicable Medicare authorities, as permitted by 42 CFR § 422.101(b)(6)(i) and (ii).

Use NCDs and LCDs of Medicare Contractors with jurisdiction in the Plan’s service area.
Apply applicable Fallon criteria only under the circumstances permitted by Medicare rules.

Note

MassHealth Medical Necessity Pathway

For MassHealth members, apply MassHealth Medical Necessity Guidelines. If MassHealth has not published an applicable guideline, Fallon may create clinical coverage criteria consistent with the definition of Medical Necessity in 130 CMR 450.204.

Use the applicable MassHealth Medical Necessity Guideline first.
Use the 130 CMR 450.204 framework when no applicable MassHealth guideline exists.

Prior Authorization

NaviCare and PACE Authorization Pathways

For NaviCare members, Fallon first applies applicable Medicare coverage authorities, including CMS NCDs, applicable LCDs, and Medicare statutes and regulations. If those authorities do not establish coverage criteria or the member does not meet them, Fallon then applies MassHealth Medical Necessity Guidelines; PACE services follow the interdisciplinary team’s authorization process.

Sequence NaviCare review through Medicare authorities first, followed by MassHealth guidelines when applicable.
For PACE, coordinate Medicare- and Medicaid-covered care and additional medically necessary services through the interdisciplinary team.

Documentation Required

Initial Authorization Documentation

Submit a completed authorization request and PCP order with documentation supporting the member’s intellectual or developmental disability and requested Day Habilitation level. Include the current SNA, Day Habilitation Leveling Tool, DHSP, and applicable behavior, therapy, nursing, or other clinical plans.

Document the functional skills or independence needs requiring Day Habilitation.
Support the requested service level with current assessments and clinical records.

Documentation Required

Nursing-Facility Resident Documentation

For nursing-facility residents, submit the required Level II PASRR or other applicable specialized-services documentation with the authorization request.

Confirm that the specialized-services documentation applies to the member’s residence and requested services.

Documentation Required

One-to-One Nursing Support

For one-to-one nursing requests, document the member’s nursing need and the interventions required, including frequency and duration. Explain why standard program staffing is insufficient to safely and appropriately furnish the service.

Describe the specific nursing interventions and staffing needs.
Include the requested frequency and duration.

Documentation Required

Reauthorization Documentation

For reauthorization, submit updated documentation demonstrating continued eligibility, medical necessity, the appropriate service level, and coordination with other programs and services.

Update the SNA, Leveling Tool, DHSP, and supporting clinical records as applicable.
Demonstrate that services remain coordinated and nonduplicative.

Documentation Required

Hospice Coordination

For members receiving hospice services, document coordination between Day Habilitation and hospice and demonstrate that the requested Day Habilitation services do not duplicate services covered by hospice.

Identify the coordination arrangements with hospice.
Explain why the requested services are distinct from hospice-covered services.

Documentation Required

Authorization and Reauthorization Documentation

Follow the documentation requirements for the applicable authorization pathway and submit complete authorization or reauthorization materials. Operational requirements include current assessments and service-level support, provider-transfer materials, and coordination documentation when applicable.

Use the applicable Medicare, MassHealth, NaviCare, PACE, or Fallon pathway.
Obtain authorization before billing and provide updated materials when circumstances or service levels change.

Denial Risk

Noncovered Service Circumstances

Day Habilitation is not covered when required prior authorization is absent, during an inpatient stay except as permitted on admission or discharge dates, or when other stated admission, discharge, or service exceptions apply.

Do not furnish services without prior authorization.
Review inpatient-stay and admission/discharge-date rules before billing.
Canceled sessions and undocumented absences are not covered.

Denial Risk

Duplication or Nonhabilitative Service

Expect denial when requested Day Habilitation duplicates hospice, nursing-facility, vocational, educational, or other covered services, or when the service is vocational, prevocational, employment-related, sheltered-workshop, or academic-education in nature.

Confirm that the requested service is habilitative and distinct from other covered programs.
Do not submit duplicative or nonhabilitative services as Day Habilitation.

Denial Risk

Insufficient Medical Necessity or Service-Level Support

Coverage may be denied when the member’s intellectual or developmental disability, functional need, medical necessity, requested service level, or ability of the program to safely furnish the service is not adequately documented.

Support the need to acquire, maintain, or improve functional skills or independence.
Ensure the SNA, Leveling Tool, DHSP, and clinical records establish the requested level.
Document that the program can safely and appropriately furnish the service.

Denial Risk

Failure to Meet Applicable Coverage Criteria or Benefit Terms

Services must satisfy applicable Medicare, MassHealth, Fallon, and member benefit-plan coverage criteria. Benefit-plan terms, exclusions, and limitations govern when they differ from this policy, subject to applicable state and federal mandates.

Consult the member’s Evidence of Coverage for product-specific exclusions and limitations.
Apply applicable Medicare or MassHealth authorities and Fallon criteria for the member’s coverage pathway.
Do not assume that a service mentioned in the policy is covered for every product or employer group.

Denial Risk

Unauthorized PACE Services

Except for emergency care and out-of-area urgently needed care, all care and services provided to PACE members must be authorized by the PACE interdisciplinary team. Unauthorized PACE services generally are not payable under the PACE pathway.

Obtain interdisciplinary-team authorization before furnishing services.
Coordinate PACE care through the assigned interdisciplinary team.
Apply the emergency and out-of-area urgently needed care exceptions when applicable.

Expected to continue indefinitely.

Functional impactResults in substantial limitations in at least three major areas of functioning, such as self-care, communication, learning, mobility, self-direction, or independent living.

Intellectual Disability (ID)

DefinitionA condition marked by significant limitations in intellectual functioning and adaptive behavior.

Affected skillsLimitations affect conceptual, social, and practical skills.

OnsetMust originate before age 22.

Applicable standardMust align with the standards set by the American Association on Intellectual and Developmental Disabilities.

Leveling Tool

DefinitionAn assessment instrument used to determine the appropriate level of Day Habilitation services for a member.

Assessment focusEvaluates the intensity of support needed to help the member acquire, maintain, or improve functional skills.

Service levelsFallon Health uses the tool to assign service levels from Level 1 through Level 4.

ReimbursementUsed to determine reimbursement rates.

Service Needs Assessment (SNA)

DefinitionA detailed evaluation conducted by the interdisciplinary team's clinical members.

Evaluation areasDetermines the member's functional abilities, strengths, and areas of need.

PurposeGuides development of the Day Habilitation Service Plan.

Update intervalUpdated every two years or upon a significant change in the member's condition.

Significant Change

DefinitionA major change in the member's medical, behavioral, cognitive, functional, or support needs.

Potential effectMay affect the member's Day Habilitation Service Plan, level of service, or eligibility.

Required responseRequires review by the interdisciplinary team and reassessment, as appropriate.