Intermittent Skilled Home Health Care — Medical Necessity and Authorization Criteria
Customize your policy alerts
Sign up for all harvard pilgrim health care policy alerts
Know when harvard pilgrim health care releases new policies or updates existing guidance.
Monitor payer policy activity
Medical necessity and authorization criteria for intermittent skilled home health care services and related billing for Harvard Pilgrim Health Care and affiliated Tufts products. Affects providers delivering home health skilled services and those requesting prior authorization/notification.
No material clinical or coverage changes in this revision.
Coverage Criteria for Intermittent Home Health Care
Intermittent home health care coverage criteria
The plan may authorize coverage when ALL of the following are met:
Providers requesting authorization after the initial evaluation visit must submit evidence of homebound status to the appropriate fax number within 2 days of the start of care (per policy).
See Definitions for 'Skilled Services'.
The plan uses InterQual® Home Care criteria to determine medical necessity and to authorize home care services after the initial evaluation visit.
Coverage for home health services excludes custodial services. Benefit availability for home care may vary by plan or group; providers must verify specific member benefits before initiating services by checking the payer website or contacting Provider Services.
For self‑insured plans, coverage may differ based on the plan's benefit document. If there is a discrepancy between this Medical Necessity Guideline and a self‑insured member's benefit document, the benefit document governs.
Custodial services are not covered as skilled home health care when the primary purpose is to meet personal needs or to maintain function and the services do not require clinical training or supervision. Such services are considered limitations to coverage and should not be billed as skilled home health.
Relevant CPT/HCPCS and Revenue Codes
| G0151 | Services of Physical Therapist in home health setting, each 15 minutes |
| G0152 | Services of Occupational Therapist in home health setting, each 15 minutes |
| G0153 | Services of Speech and Language Pathologist in home health setting, each 15 minutes |
| G0155 | Services of Clinical Social Worker in home health setting, each 15 minutes (not applicable to Tufts Health Together) |
| G0156 | Services of Home Health Aide in home setting, each 15 minutes |
| G0157 | Services performed by a qualified physical therapy assistant in the home health setting, each 15 minutes |
| G0158 | Services performed by a qualified occupational therapy assistant in the home health setting, each 15 minutes |
| G0159 | Services performed by a qualified physical therapist in the home health setting, in the establishment or delivery of a physical therapy maintenance program, each 15 minutes |
| G0160 | Services performed by a qualified occupational therapist in the home health setting, in the establishment or delivery of an occupational therapy maintenance program |
| G0161 | Services performed by a qualified speech-language pathologist in the home health setting, in the establishment or delivery of a speech-language pathology maintenance program, each 15 minutes |
| 0551 | Skilled Nursing, visit charger (per visit up to 2 hours) |
| 0552 | Skilled Nursing, hourly charge (each additional hour after the first two hours) |
| 0559 | Skilled Nursing, other (LPN nursing, per visit) |
| 0551 | Skilled Nursing, visit charger (per visit up to 2 hours) |
| 0552 | Skilled Nursing, hourly charge (each additional hour after the first two hours) |
| 0559 | Skilled Nursing, other (LPN nursing, per visit) |
Prior Authorization, Notification, and Documentation Requirements
Obtain prior authorization after initial/30 days (Commercial)
For Commercial products, prior authorization is required for home health services after the initial evaluation visit and after the first 30 days of service; providers requesting authorization after the initial evaluation must submit evidence of homebound status to the appropriate fax number within 2 days of the start of care. The plan uses InterQual® Home Care criteria to determine medical necessity and to authorize services.
- Prior authorization required for services beyond the first 30 days for Commercial Products.
- Submit evidence of homebound status within 2 days of start of care when requesting authorization after the initial evaluation.
- Authorization determinations use InterQual® Home Care criteria.
Timely prior authorization/notification to avoid denial
Failure to obtain required prior authorization for services beyond the first 30 days (Commercial products) or failure to submit required notification within 2 business days from the first date of service may result in denial of payment or affect coverage.
- Notification must be submitted within 2 business days from the first date of service for Commercial Products.
- Prior authorization is required for services beyond the first 30 days for Commercial Products; lack of PA may result in denial of payment.
Notification and prior authorization affect coverage
Failure to submit required notification for the first 30 days of service or to obtain prior authorization for subsequent services may affect coverage for Tufts Health Commercial and Harvard Pilgrim Health Care Commercial products as noted in MPAC history.
- Notification required for first 30 days; prior authorization required thereafter for Commercial products per MPAC decision.
- Coverage impact applies to Tufts Health Commercial and Harvard Pilgrim Health Care Commercial Products.
Notable code change: 99501 removed from PA (effective 2026-01-01)
Code 99501 was removed from the guideline and will be covered without prior authorization effective January 1, 2026; review MPAC revision history for code-specific PA status.
- Code 99501 removed from prior authorization requirement effective January 1, 2026.
- Check MPAC approval and revision history for other code changes and effective dates.
Submit clinical documentation via HPHConnect or fax when requested
When requested for authorization or medical necessity review, submit clinical notes and written documentation via HPHConnect Clinical Upload or secure fax (800-232-0816); providers may be asked to provide updated clinical information to qualify for continued service.
- Use HPHConnect Clinical Upload or secure fax (800-232-0816) to submit supporting clinical documentation.
- Be prepared to provide updated clinical information for continued services if requested.
Coverage and claims subject to benefit document and claims review
Coverage decisions are made using these Medical Necessity Guidelines in conjunction with the member's benefit document and coordination with the member's physician; claims payment remains subject to eligibility, benefits on the date of service, coordination of benefits, referral/authorization, utilization management guidelines, and claims editing/pricing review.
- Member's benefit document governs for self-insured plans if discrepancies exist.
- Claims are subject to eligibility, benefits on date of service, coordination of benefits, referral/authorization, utilization management guidelines, and claims editing/pricing review.
Ensure PA/notification is obtained and provide updates as required
Providers are responsible for ensuring any necessary prior authorization or notification has been obtained as a condition of payment; even if not the entity obtaining the PA, providers must confirm PA/notification is in place and may need to provide updated clinical information to qualify for continued service.
- As a condition of payment, ensure required prior authorization has been obtained and/or Point32Health has received proper notification.
- Providers may need to supply updated clinical information for ongoing authorization or concurrent review.
Use HPHConnect and submit supporting documentation to complete authorization
Providers must follow the plan’s authorization process via HPHConnect (automated authorization questionnaire) and may be required to submit supporting clinical documentation electronically or by secure fax to complete medical necessity review.
- Request authorization and complete the automated authorization questionnaire via HPHConnect.
- Submit supporting clinical documentation electronically (recommended) or by secure fax when requested.
Background on Home Health Services
Home health care provides skilled services — for example, nursing, physical therapy, occupational therapy, and speech‑language pathology — and qualified home health aide services delivered in the Member's residence to treat illness or injury and achieve specified medical outcomes. Services must be part of a physician‑established plan of care and are authorized based on the guideline in coordination with the Member's benefit document and treating physician.
Key Definitions
Policy Approval and Revision Events
Reviewed by the Medical Policy Approval Committee for 2026 InterQual update and administrative template updates; effective July 1, 2026.
Reviewed by MPAC and code 99501 removed from guideline to be covered without prior authorization effective January 1, 2026.
Reviewed by MPAC for annual review and renewed without changes effective October 1, 2025.
Fax number for Senior Care Options, Tufts Medicare Preferred HMO and Tufts Medicare Preferred PPO updated and Carelink language removed.
Reviewed by MPAC for 2025 InterQual upgrade; effective July 1, 2025.
Reviewed by MPAC and renewed without changes effective December 1, 2024.
Reviewed by MPAC for 2024 InterQual upgrade; effective July 1, 2024.
Reviewed by MPAC to require notification for the first 30 days of service and prior authorization for subsequent services for Tufts Health Commercial and Harvard Pilgrim Health Care Commercial products effective April 12, 2024.
Rebranded Unify to One Care effective January 1, 2024.
Reviewed by MPAC and renewed without changes.
Reviewed by MPAC and renewed without changes; removal of codes 99601 and 99602 from the policy and from prior authorization for HPHC effective August 1, 2023.
Reviewed by MPAC for integration between Harvard Pilgrim Health Care and Tufts Health Plan; effective February 1, 2023.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.