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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyHealth New England Home Health Coverage | OpenPaye…
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    CurrentHealth New EnglandPolicy UM670POL

    Home Health Care Services - Medical Policy

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    This policy governs medical necessity, authorization, documentation, and coding guidance for home health and hospice-setting services for Health New England Commercial and Medicare Advantage members. Covered home health services are evaluated using adopted InterQual criteria, with Medicare services also subject to applicable CMS home health requirements.

    Policy Summary
    PayerHealth New England
    PolicyHome Health Care Services - Medical Policy
    Policy CodePolicy UM670POL
    Change TypeMaterial update
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionSubmit a HOME HEALTH CERTIFICATION AND PLAN OF CARE (CMS-485) containing the treatment plan and addressing the member's homebound status.
    SourceLink
    POLICY UPDATE CHANGES

    Documentation requirements were added for the CMS-485 and homebound status.

    Medicare global criteria for covered home health services were added by reference to CMS Home Health Services guidance.

    Policy language was clarified without changing medical necessity criteria.

    2Applicable lines of business
    20Adopted InterQual criteria sets
    21HCPCS codes listed
    CMS-485Required certification and plan of care
    HomeboundRequired member status

    Medical Necessity and Eligibility

    InterQual medical necessity criteria

    Covered when the applicable adopted InterQual criteria are met.

    Applicable InterQual service criterion

    • Adult services: Use the applicable adult InterQual criterion for the requested service.
    • Pediatric services: Use the applicable pediatric InterQual criterion for the requested service.

    Required home health documentation and homebound status

    Covered homecare services require all of the following documentation and eligibility elements.

    Home health certification and eligibility

    • CMS-485: Submit the home health certification and plan of care with the treatment plan.CMS-485
    • Homebound status: Document that the member is homebound.

    Medicare home health eligibility

    Medicare coverage requires all applicable Medicare global home health criteria in addition to the applicable InterQual service criterion.

    Medicare global criteria: For Medicare members, the applicable CMS global criteria for covered home health services must be met.

    The policy incorporates CMS Home Health Services guidance. The adopted InterQual criteria are based on Chapter 7 of the Medicare Benefit Policy Manual.

    Unskilled or custodial services are excluded from the skilled home health service definition when they are not contingent on a skilled nursing or therapy need and consist of non-medical care that can reasonably and safely be provided by non-licensed caregivers.

    Home Health and Hospice Coding

    Home health and hospice HCPCS codesHCPCS
    G0151Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
    G0152Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
    G0153Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
    G0155Services of clinical social worker in home health or hospice settings, each 15 minutes.
    G0156Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
    G0157Services performed by a qualified physical therapy assistant in the home health setting, each 15 minutes.
    G0158Services performed by a qualified occupational therapy assistant in the home health setting, each 15 minutes.
    G0159Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
    G0160Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
    G0161Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.
    1–10 of 21
    1/3

    Submission and Review Requirements

    Documentation Required

    Use InterQual and CMS Criteria

    Apply the applicable InterQual Home Care Q&A criteria for the member’s age group and requested service, together with applicable CMS requirements. HNE uses these criteria for Commercial and Medicare medical-necessity review; Medicare InterQual criteria are based on CMS Chapter 7 of the Medicare Benefit Policy Manual.

    • Adult: Home Health Aide; Home Occupational Therapy and Evaluation; Home Physical Therapy and Evaluation; Home Skilled Nursing and Evaluation; Home Social Worker; Home Speech Therapy and Evaluation.
    • Pediatric: Home Health Aide; Home Occupational Therapy and Evaluation; Home Physical Therapy and Evaluation; Home Skilled Nursing and Evaluation; Home Social Worker; Home Speech Therapy and Evaluation.
    • For Medicare members, also apply the CMS global criteria for covered home health services.
    Documentation Required

    Submit the CMS-485 and Homebound Documentation

    Submit the HOME HEALTH CERTIFICATION AND PLAN OF CARE (CMS-485), including the treatment plan, and document that the member meets the applicable homebound or confined-to-home requirements.

    • The documentation must address homebound status because members must be homebound to receive homecare services.
    • For Medicare, use the applicable CMS global criteria for covered home health services.
    Documentation Required

    Provide Clinical Evidence

    The treating physician or primary care provider must submit clinical evidence showing that the patient meets the applicable medical-necessity criteria. Without sufficient clinical evidence and supporting information, HNE cannot properly review the request for prior authorization.

    • Include evidence supporting the requested skilled service, treatment plan, and medical necessity.
    • Ensure the submitted information is specific enough to support review under the applicable InterQual and CMS criteria.
    Billing Rule

    Follow Request Submission Requirements

    Follow the request-submission requirements in HNE’s Skilled Home Health Care payment policy and the applicable provider submission guidance. Postpartum Home Visiting Services are governed by the applicable statute and do not require prior authorization under the cited guidance.

    • Use the Skilled Home Health Care payment policy for requirements on request submission.
    • Registered HNE providers can access InterQual SmartSheets through the HNE provider portal; providers without portal access may call (413) 787-4004 to obtain a copy.
    Denial Risk

    Confirm Homebound Status

    Flag cases in which the member is not homebound or confined to the home, because failure to meet this requirement may result in a medical-necessity failure. Document the functional and medical basis for the member’s inability to leave home.

    • The member generally must need supportive devices, special transportation, or another person to leave the residence, or have a condition for which leaving home is medically contraindicated.
    • There must be a normal inability to leave home, and leaving home must require a considerable and taxing effort.
    Denial Risk

    Address Insufficient Clinical Documentation

    Identify and resolve missing clinical evidence or treatment-plan documentation before submitting the request. HNE cannot properly review or approve a request when the record does not demonstrate that the patient meets the applicable criteria.

    • Check for the CMS-485, treatment plan, homebound-status documentation, and clinical evidence from the treating physician or primary care provider.
    • Insufficient documentation may prevent prior-authorization review or result in non-approval.
    Denial Risk

    Watch for Custodial or Unskilled Services

    Flag services that are custodial or unskilled and do not depend on a skilled nursing or therapy need, because they may not qualify as skilled home health care. Non-medical care that can reasonably and safely be provided by non-licensed caregivers is considered unskilled or custodial service.

    • Skilled home health care is intended to provide intermittent skilled services to restore or maintain the member’s maximal level of function and health.
    • Home health aide or other support is not sufficient by itself when it is not contingent on a skilled nursing or therapy need.

    Skilled Home Health Care Overview

    Skilled home health care consists of intermittent skilled services provided in the member’s home to restore or maintain the member’s maximal level of function and health. These services are furnished in lieu of hospitalization, confinement in an extended-care facility, or leaving the home to receive treatment.

    Key Terms

    Activity of Daily Living (ADL)
    DefinitionDaily self-care activities performed in the course of a normal day.
    ExamplesBathing, dressing, eating, toileting, and transferring.
    Activity typeBasic self-care activities, rather than more complex instrumental activities.
    Confined to Home
    DefinitionA condition in which illness or injury requires assistance or makes leaving the residence medically contraindicated.
    Support or assistanceThe member may need supportive devices such as crutches, canes, wheelchairs, or walkers; special transportation; or another person's assistance to leave the residence.
    Required limitationThere must be a normal inability to leave home, and leaving home must require a considerable and taxing effort.
    Cueing
    DefinitionA signal used to support a specific action.
    FormsA word or phrase used to prompt an action.
    PurposeTo provide a reminder or hint of something.
    Home Health Agency (HHA)
    DefinitionAn agency primarily engaged in providing skilled nursing services and other therapeutic services.
    Primary servicesSkilled nursing and therapeutic services.
    Care settingSkilled home health care is provided to a member in the home to restore and maintain the member's maximal level of function and health.
    Home Health Aide (HHA)
    DefinitionA trained and certified health-care worker who provides assistance to a patient in the home.
    Training statusThe worker is trained and certified.
    Primary assistancePersonal care provided in the patient's home.
    Instrumental Activity of Daily Living (IADL)
    DefinitionDaily activities that require more complex skill than activities of daily living.
    Skills requiredThese activities require physical skill, sound judgment, and organizational skill.
    ExamplesManaging money, shopping, housekeeping, and preparing meals.
    Intermittent Skilled Nursing Care
    DefinitionSkilled nursing care provided or needed on fewer than 7 days each week or less than 8 hours of each day.
    Standard durationCare is provided or needed for periods of 21 days or less.
    ExtensionsExtensions may be allowed in exceptional circumstances when the need for additional care is finite and predictable.
    Supervision
    DefinitionThe act of watching and directing.
    Core functionWatching an activity or person.
    DirectionProviding direction during the activity or care.
    Unskilled or Custodial Service
    DefinitionA home health service that is not contingent on a skilled nursing or therapy need.
    Nature of careNon-medical care.
    Who may provide itCare that can reasonably and safely be provided by non-licensed caregivers.
    Policy Summary
    PayerHealth New England
    PolicyHome Health Care Services - Medical Policy
    Policy CodePolicy UM670POL
    Change TypeMaterial update
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionSubmit a HOME HEALTH CERTIFICATION AND PLAN OF CARE (CMS-485) containing the treatment plan and addressing the member's homebound status.
    SourceLink
    On This Page
    Medical Necessity and EligibilityHome Health and Hospice CodingSubmission and Review RequirementsSkilled Home Health Care OverviewKey Terms

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