ModifiedIndiana Department of InsurancePolicy PROMOD00032

Home Health Services

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Indiana Health Coverage Programs fee-for-service coverage, medical necessity, prior authorization, care coordination, billing, and reimbursement for part-time and intermittent home health services provided to Medicaid members of any age in their place of residence. Managed care providers must follow their managed care entity's requirements.

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ModifiedIndiana Department of InsurancePolicy PROMOD00032

Home Health Services

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Sign up for Indiana Department of Insurance Policy PROMOD00032 alerts

Get alerted when Policy PROMOD00032 changes without checking for updates manually.

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Policy Summary

PayerIndiana Department of Insurance

PolicyHome Health Services

Policy CodePolicy PROMOD00032

Change TypeModified

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for home health services and submit documentation supporting medical necessity, the written order, plan of care, and certification requirements.

SourceLink

POLICY UPDATE CHANGES

Version 8.1 added PathWays information to the initial note, a Traveling With a Member section, Care Coordination Considerations and subsections, and additional prior authorization requirements for assisted living facility residents.

Version 8.1 updated IHCP coverage, certification of medical necessity, home health prior authorization policies, PA documentation, nursing and aide PA, and the PA exception for verification.

Version 8.1 added the Care Coordination Considerations section and updated the policy's coordination guidance for home health provided with hospice.

Version 8.1 removed the section on coordinating home health services with attendant care and structured family caregiving for HCBS waiver members.

All servicesHome health services generally require prior authorization

60 daysRequired plan-of-care review interval

Any ageMember age range for home health eligibility

12 or 16 hours/dayPotential daily skilled-service authorization limits

21+Age threshold for hospice-related concurrent home health restriction

Coverage Criteria

Home health eligibility indicators

At least one indicator from each category must be present for home health eligibility.

Eligibility indicators

Category I: Member: The member is at risk of respiratory failure, severe deterioration, or hospitalization without constant monitoring; requires total care with monitoring 24 hours per day; desires to remain at home rather than in a long-term care facility; or has a deteriorated medical condition creating a need for more intense short-term care.At least 1
A practitioner's statement is required for the deteriorated-condition indicator.
Category II: Caregiver: The member lacks a primary caregiver or access to other care; the caregiver is absent or unable to provide necessary care; the caregiver has qualifying childcare responsibilities; the caregiver has a child with special healthcare needs; the caregiver has a major illness or injury with expected recovery; caregiver availability changes temporarily and significantly; or caregiver status changes permanently and significantly, such as death or divorce with loss of a caregiver.At least 1
The listed caregiver circumstances are alternatives.

General coverage requirements

Home health services are covered when all of the following core conditions are met.

Core coverage conditions: Services are medically necessary; ordered in writing by an enrolled qualified attending practitioner; performed on a part-time and intermittent basis under a written plan of care reviewed every 60 days; and supported by required medical-necessity certification and prior authorization.All conditions required

The qualified attending practitioner may be a physician, nurse practitioner, clinical nurse specialist, or physician assistant.

Medical necessity certification

Medical necessity certification is required at initiation and at specified subsequent intervals.

Face-to-face certification: A face-to-face encounter with the certifying practitioner is required at initiation, after an interruption of 60 days or more from the end of the last authorization period, and on a rolling 12-month basis for long-term services.Initial: no more than 90 days before or 30 days after the start of services; annual: within 90 days before or 30 days after the anniversary date of the previous year's encounter

The encounter may occur in person or through compliant telehealth. Reorders within a continuous one-year period do not require a new encounter unless home health hours increase.

Home health in addition to hospice

Concurrent home health and hospice coverage depends on the member's age and the relationship of home health treatment to the terminal diagnosis.

Hospice coordination: A member age 21 or older enrolled in the IHCP or Medicare hospice benefit cannot concurrently receive IHCP home health services outside the hospice per diem for treatment of the terminal diagnosis or related conditions. A member age 20 or younger who elects IHCP hospice may receive concurrent curative treatment of the terminal illness through home health services.Age 21+ restricted; age 20 or younger may receive concurrent curative treatment

Services reimbursed under the hospice per diem are not subject to the concurrent home health restriction.

Home health hourly determination

Authorized hours are determined through individualized review using the member's clinical needs and available caregiver support.

Hourly determination: Review the severity and stability of illness and symptoms; changes in condition; the plan of care and goals; intensity and complexity of care; treatment time; consistency with prior plans of care; teaching needs; other home care services; the member's work or school schedule; caregiver availability; caregiver work, school, childcare, and physical limitations; and the requested hours compared with available caregiver time.Individual case review

These guidelines do not override medical decisions based on individual case review. The provider must coordinate services with caregiver work or school schedules.

Home health nursing and aide services

Home health nursing and aide services are covered when all of the following conditions are met.

Nursing and aide coverage: Services are ordered in writing by a qualified practitioner within the practitioner's scope of practice; provided under a written plan of care developed by the qualified attending practitioner; medically necessary; less expensive than any alternate mode of care; and provided in accordance with all applicable nursing-service requirements.All conditions required

Written evidence of qualified practitioner involvement and personal member evaluation, a current plan of care, and progress notes documenting necessity and effectiveness are required.

Home health therapy services

Home health therapy services are covered when all of the following conditions are met.

Therapy coverage: Therapy is ordered in writing by a qualified practitioner within the practitioner's scope of practice; provided by an appropriately licensed, certified, or registered therapist employed or contracted by the home health agency; provided under a written plan of care developed cooperatively by the therapist and qualified practitioner; medically necessary; and provided in accordance with all applicable therapy requirements.All conditions required

Orders must specify the procedures and modalities to be used and the amount, frequency, and duration of each. Written evidence of practitioner involvement and personal member evaluation, a current plan of care, and progress notes documenting necessity and effectiveness are required.

Up to 12 hours per day

Up to 12 hours per day may be authorized when the member requires 24-hour monitoring and skilled nursing or home health aide services are needed to prevent deterioration in life-sustaining systems.

High-acuity conditions: Examples include severe respiratory conditions, pulmonary disorders such as bronchopulmonary dysplasia, cystic fibrosis, bronchitis or asthma, central nervous system disorders, cardiovascular disorders such as cardiac anomalies, neuromuscular disorders such as muscular dystrophy or Guillain-Barré syndrome, mechanical ventilator dependence, or tracheostomy.Up to 12 hours/day

The examples are not exhaustive.

Special situations for up to 16 hours per day

Up to 16 hours per day of ongoing skilled care may be authorized only after individual evaluation through a prior authorization request when a special situation is documented.

Special caregiver situations: A single caregiver is available and works full-time or a significant number of part-time hours; one of two adults is unable to provide meaningful care because of physical disability or severe physical limitations; or the caregiver has significant additional childcare responsibilities.Up to 16 hours/day

Significant childcare responsibilities mean three or more children under age 6, four or more children under age 10, or one or more children with special medical care needs requiring extensive medical and physical care beyond the needs of an average well child.

Up to 8 hours per day

Up to eight hours per day may be authorized when the member requires extensive care and daily monitoring but does not have the same immediate risk of rapid, life-threatening deterioration as a member requiring 24-hour monitoring.

Extensive care examples: Examples include quadriplegia; severe cerebral palsy; muscular dystrophy; spina bifida or other congenital anomalies; central lines or Hickman catheters; hyperalimentation or gastrostomy tube feedings; frequent physical or occupational therapy; skilled nursing assistance to attend school; or multiple medications requiring monitoring for severe side effects or responses.Up to 8 hours/day; an additional 1 or 2 hours may be allowed for caregiver transportation to and from work

The examples are not exhaustive.

Three to seven hours per day

Three to seven hours per day may be authorized when the member is generally stable but requires heavy physical care and some skilled nursing monitoring to avoid deterioration.

Moderate-care examples: Examples include congenital anomalies, neuromuscular disorders, central nervous system disorders, or other disorders that severely disrupt the capacity for self-care. Consideration may also be given to paraplegic, quadriplegic, or other disabled adults who cannot bathe or dress themselves but can maintain meaningful employment and community involvement.3 to 7 hours/day; up to 4 hours/day for qualifying home health aide assistance

The service is subject to medical necessity, and documentation must demonstrate the member's need. Hours may be split between morning and evening to address bedtime needs.

Temporary additional hours

Additional units may be authorized for a short period when a documented change in the member's condition or home circumstances supports a transition or helps prevent inpatient or extended inpatient admission.

Temporary or permanent changes: Significant deterioration in the member's condition, particularly when additional hours may prevent inpatient or extended inpatient admission; major caregiver illness or injury with expected recovery; temporary but significant caregiver unavailability due to military duty or employment responsibilities; or a significant permanent change in the home situation, such as death or divorce with loss of a caregiver.Short-term additional units

Examples of caregiver illness or injury include an acute-care admission, chemotherapy or radiation, or a broken limb that impairs lifting. Additional units may assist with a transition.

The home health benefit does not cover transportation to grocery stores, pharmacies, banks, or similar destinations; homemaker services such as shopping, laundry, cleaning, or meal preparation; chores and errands; sitter or companion services; or respite care.

Home health services are not provided in hospitals, nursing facilities, or intermediate care facilities for individuals with intellectual disabilities (ICF/IID). They are also excluded from settings where Medicaid inpatient payment that includes room and board is, or could be, made.

For a member residing in an assisted living facility, home health services that duplicate services the facility must provide under its per diem reimbursement are not payable. The prior authorization request must report POS code 13, and the provider must verify that the requested services are not duplicative.

When a member refuses service after the therapist, home health aide, LPN, or RN enters the home, the provider may not bill any service units. Overhead is also not payable when the provider does not render a service, including when the member refuses the service.

Rotating personnel in the home solely to increase billing is not appropriate. When multiple visits for the same prior-authorized service occur on one day, providers must report them on the same claim form and one detail with the total units provided, rather than submitting separate details that may be denied as duplicate services.

No reimbursement is available when the provider does not render a service. If a therapist, home health aide, LPN, or RN enters the home but no service is provided, the provider may not bill any unit or overhead.

For home uterine monitoring infusion therapy, supplies associated with the therapy are bundled into the daily rate and may not be billed separately. Providers may bill one unit daily for procedure codes 99601 or 99602 using revenue code 559, but may not bill overhead when the daily infusion service does not include an actual home encounter.

Three-to-seven-hour services may be authorized for members who are generally stable but require heavy physical care and some skilled nursing monitoring to avoid deterioration. The service is subject to medical necessity, and documentation must demonstrate the member’s need. Qualifying adults may receive home health aide assistance for up to 4 hours per day, including hours split between morning and evening when needed for bedtime care.

Home health nursing, aide, and therapy services must be medically necessary and supported by the required practitioner evaluation, written order, and current written plan of care. Nursing and aide services must be ordered by a qualified practitioner, provided under the practitioner’s plan of care, be less expensive than an alternate mode of care, and meet applicable nursing requirements. Therapy must be delivered by an appropriately licensed, certified, or registered therapist under a plan of care developed cooperatively with the qualified practitioner; therapy orders must specify the procedures, modalities, amount, frequency, and duration. Progress notes and evidence of practitioner involvement and personal member evaluation must support the request and be retained for review.

Coding and Billing Reference

Home health procedure codesHCPCSCovered

99600	Unlisted home visit, service, or procedure; used for home health aide services and home health nursing requests
99600 TD	Unlisted home visit, service, or procedure with Registered nurse (RN) modifier
99600 TE	Unlisted home visit, service, or procedure with Licensed practical nurse (LPN) modifier
G0151	Physical therapist
G0152	Occupational therapist
G0153	Speech-language pathologist

Occurrence codesmixed

73	Overhead; one unit per provider per member per day

Hospital discharge billing codemixed

42	Occurrence code used with the hospital discharge date to bypass PA requirements within the discharge exception parameters

Nursing modifiersModifier

TD	Registered nurse (RN)
TE	Licensed practical nurse (LPN)

Revenue codes and corresponding procedure codesRevenue

420	G0151
421	G0151
422	G0151
423	G0151
424	97161 - 97163
429	G0151
430	G0152
431	G0152
432	G0152
433	G0152

1–10 of 21

1/3

Revenue codes and corresponding procedure codesmixed

420	Revenue code corresponding to G0151
421	Revenue code corresponding to G0151
422	Revenue code corresponding to G0151
423	Revenue code corresponding to G0151
424	Revenue code corresponding to 97161 - 97163
429	Revenue code corresponding to G0151
430	Revenue code corresponding to G0152
431	Revenue code corresponding to G0152
432	Revenue code corresponding to G0152
433	Revenue code corresponding to G0152

1–10 of 31

1/4

Initial therapy evaluation codes in home settingsmixed

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance

1–10 of 13

1/2

Home uterine monitoring device billingmixedCovered

99601	Home infusion/specialty drug administration, per visit (up to two hours)
99602	Home infusion/specialty drug administration, per visit (up to two hours); each additional hour
559	Revenue code required when billing 99601 or 99602

Pharmacy billing for home infusion and enteral therapyNDC

NDC	National Drug Code required for compound drugs or drugs used in parenteral therapy

Initial face-to-face encounter

Timing before servicesNo more than 90 days before the start of services

Timing after services beginNo more than 30 days after the start of services

Applies toInitial face-to-face certification

Long-term face-to-face encounter

Review cycleRolling 12-month basis

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required for Home Health

Home health services require PA and must be medically necessary, ordered in writing by an enrolled qualified attending practitioner, and furnished part-time and intermittently under a written plan of care reviewed every 60 days. Submit medical-necessity certification and supporting documentation with the PA request.

Qualified practitioners: physician, nurse practitioner, clinical nurse specialist, or physician assistant.
Services must follow the written plan of care.

Prior Authorization

Obtain Approval for Staff Travel

Include anticipated member travel for other services in the home health PA request. Staff may travel with the member only with prior approval and only when the staff member meets in-state and, when applicable, out-of-state licensure requirements.

A home health aide or nurse may accompany the member to medically necessary appointments but may not drive the member.
This guidance applies to fee-for-service coverage; managed care policies may differ.

Policy Background

Home health services are part-time and intermittent services provided to Medicaid members of any age in the member’s place of residence. Covered services include skilled nursing, home health aide services, and skilled therapies. Eligibility and authorized service levels are based on medical necessity, the member’s clinical needs, and caregiving circumstances; homebound status is not required.

Definitions and Reference Terms

Home health services

DefinitionServices provided on a part-time and intermittent basis

Eligible membersMedicaid members of any age

Place of residenceA setting where normal life activities take place, excluding hospitals, nursing facilities, ICF/IID facilities and settings where Medicaid inpatient room-and-board payment is or could be made

Qualified attending practitioner

Ordering physicianPhysician who orders and develops the written plan of care

Other practitioner typesNurse practitioner, clinical nurse specialist or physician assistant

Ongoing responsibility

Policy Summary

PayerIndiana Department of Insurance

PolicyHome Health Services

Policy CodePolicy PROMOD00032

Change TypeModified

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for home health services and submit documentation supporting medical necessity, the written order, plan of care, and certification requirements.

SourceLink

On This Page

Timing before anniversaryWithin 90 days before the anniversary date of the previous year's encounter

Timing after anniversaryWithin 30 days after the anniversary date of the previous year's encounter

Continuous-year reorder exception

Eligible reordersReorders within a continuous one-year period

Face-to-face requirementNot required for continued medical necessity reorders

ExceptionA new encounter is required if home health hours increase

Potential standard daily authorization

Maximum authorizationUp to 12 hours per day

Covered servicesSkilled nursing or home health aide services

Clinical circumstanceMembers requiring 24-hour monitoring to prevent deterioration in life-sustaining systems

Potential special daily authorization

Maximum authorizationUp to 16 hours per day

Service typeOngoing skilled care

Review requirementEach individual situation must be evaluated with a prior authorization request

Caregiver childcare indicator

First qualifying thresholdThree or more children under 6 years of age

Alternative thresholdFour or more children under 10 years of age

Additional qualifying circumstanceOne or more children with special healthcare needs requiring extensive medical and physical care

High-acuity skilled monitoring

Standard limitUp to 12 hours per day

Special-situation limitUp to 16 hours per day

Care typeSkilled nursing or home health aide services for members requiring 24-hour monitoring

Extensive daily care

Daily limitUp to 8 hours of home health care daily

Work transportationAn additional 1 or 2 hours may be allowed for transportation to and from work

Clinical circumstanceExtensive care and daily monitoring without the same immediate life-threatening deterioration risk as 24-hour-monitoring cases

Moderate physical and skilled care

Daily rangeThree to seven hours of home health care per day

Aide assistanceCertain adults may receive home health aide assistance for up to four hours per day

Scheduling optionHours may be split between morning and evening for bedtime needs

Hospital discharge nursing and aide exception

Covered servicesRN, LPN and home health aide services

MaximumNot more than 120 units

Post-discharge periodWithin 30 calendar days following discharge; the discharge date is day 1

Hospital discharge therapy exception

Covered servicesAny combination of occupational therapy, physical therapy and speech-language pathology services

MaximumNot more than 30 combined units

Post-discharge periodWithin 30 calendar days following discharge; additional services require prior authorization

Therapy billing unit

Unit definitionOne therapy unit equals 15 minutes

Rounding thresholdEight minutes or more in the home may be rounded up to one 15-minute unit

Below thresholdFewer than eight minutes is not billable

Nursing and aide billing unit

Unit definitionOne nursing or aide unit equals one hour

Round upAfter the first hour, partial units of 30 minutes or more round up to the next unit

Round downAfter the first hour, partial units of 29 minutes or less round down

Therapy visit unit

Unit definitionOne therapy visit unit equals 15 minutes

Round upEight minutes or more in the home rounds up to one 15-minute unit

Nonbillable visitFewer than eight minutes in the home cannot be billed

Nursing and aide visit unit

Unit definitionOne nursing or aide visit unit equals one hour

First-hour ruleIf fewer than 29 minutes are spent in the home, the first hour may be billed only if a service was provided

Subsequent partial units30 minutes or more rounds up; 29 minutes or less rounds down

Home uterine monitoring daily limit

Applicable codes99601 and 99602

Daily limitOne unit of service daily

Required revenue codeRevenue code 559

NEMT must be furnished by an IHCP-enrolled transportation provider and arranged through Verida for FFS members.

Unsupported block type: prior_auth

Prior Authorization

Submit PA for Home Health Services

All home health services require PA unless the hospital-discharge exception applies. An authorized agency representative must submit the request and supporting medical-necessity documentation; requests may be submitted through the PA portal, 278 transaction, form, mail, fax, or phone with documentation.

A written PA revision is required for increased services.
The hospital-discharge exception is limited to the applicable RN, LPN, aide, and therapy units and time period.

Documentation Required

Submit or Revise the PA

The authorized home health agency must submit or revise PA requests. A service increase requires a written PA revision with supporting documentation demonstrating medical necessity.

Use the provider portal, 278 transaction, PA form, mail, fax, or telephone submission as permitted.
Telephone requests do not replace required supporting documentation.

Prior Authorization

Therapy PA Requirements

PA is required for home health occupational, physical, and speech-language therapy except for qualifying written orders issued before inpatient discharge. Therapy must be delivered by an appropriately licensed, certified, or registered therapist under a written plan of care.

The discharge exception is limited to a combined 30 therapy units within 30 days after discharge.
Orders must specify procedures and modalities, amount, frequency, and duration.
Attach practitioner involvement and evaluation documentation, the current plan of care, and therapy progress notes.

Documentation Required

Support the Hourly Service-Level Determination

Determine requested hourly services through individualized review rather than relying solely on guideline ranges. Document severity and stability, changes in condition, intensity and complexity of care, treatment time, goals, and consistency with prior plans.

Consider available caregivers, work or school schedules, remote or in-person work, childcare responsibilities, physical limitations, and requested hours versus caregiver availability.
Account for other services and programs, including Medicare, waivers, CHOICE, vocational rehabilitation, and private insurance.
Short-term additional hours may be supported by significant deterioration, caregiver illness or injury, temporary home changes, military duty, employment unavailability, or permanent caregiver loss.

Prior Authorization

PA for Skilled Home Health Services

PA is required for RN, LPN, and home health aide services unless the hospital-discharge exception applies. Services must be ordered in writing, medically necessary, less expensive than an alternate mode of care, and furnished under the qualified practitioner’s written plan of care.

Attach evidence of practitioner involvement and personal patient evaluation, a current plan of care, and progress notes addressing necessity and effectiveness.
Use procedure code 99600 for aide services and 99600 with modifier TD for nursing PA requests; the RN/LPN level is reported on the claim.

Denial Risk

Do Not Render Services Without Required Eligibility, Certification, or PA

A home health PA must include a written order, medical-necessity certification, required face-to-face documentation, and a current plan of care. Missing eligibility, certification, or PA requirements can prevent coverage or result in denial.

Initial orders require a face-to-face encounter within 90 days before or 30 days after service starts; annual and interruption-related requirements also apply.
A continuous-year reorder generally does not require a new face-to-face encounter unless hours increase.
Keep required documentation available for postpayment review.

Denial Risk

Noncovered Homemaker, Transportation, and Companion Services

Do not bill the home health benefit for transportation to stores, pharmacies, banks, or errands; homemaker, chore, sitter, companion, or respite services are also noncovered. Other Medicaid benefits or HCBS waivers may cover some services separately.

Excluded homemaker activities include shopping, laundry, cleaning, and meal preparation.
Transportation to a pharmacy may be covered as a Traditional Medicaid benefit when applicable.

Denial Risk

Check for Concurrent Hospice Restrictions

Members age 21 or older receiving the IHCP hospice benefit may not concurrently receive IHCP home health services outside the hospice per diem for the terminal diagnosis or related conditions. Members age 20 or younger may receive qualifying concurrent curative treatment, including home health services.

The restriction also applies when hospice services are furnished under Medicare.

Denial Risk

Stay Within the Hospital-Discharge Exception

For hospital-discharge services, a qualifying written order must be issued before discharge. Use occurrence code 42 and the discharge date on the institutional claim to bypass PA only within the stated limits.

RN, LPN, and aide services: no more than 120 units within 30 calendar days; discharge day is day 1.
Combined therapy services: no more than 30 units within 30 calendar days.
Services beyond these limits require PA; otherwise Core MMIS automatically denies or reduces units.

Documentation Required

Submit Core PA Documentation

Attach the required face-to-face record, CMS 485, comprehensive assessment, OASIS-related information, and supporting plan-of-care materials to the PA request. The face-to-face record is required initially, annually, after an interruption of 60 days or more, and for increases, but generally not for uninterrupted continuation within 12 months.

The assessment must identify other supportive services and therapies and whether agency staff are the member’s parent or legally responsible individual.
The qualified attending practitioner must sign the current plan of care.

Documentation Required

Maintain the Assessment and Plan of Care

The plan of care must be current through the request date, developed with the qualified attending practitioner, agency personnel, and applicable therapists, and signed by the practitioner completing the assessment. Keep copies at the agency and member’s home and document practitioner review and reorder every 60 days.

Include OASIS and all information required by 42 CFR 484.55(c).
Document member involvement, awareness, acknowledgment, and receipt of the plan when applicable.

Documentation Required

Include Required Plan-of-Care Elements

Include every required clinical and service detail in the written plan of care so the request supports medical necessity and service delivery.

Start-of-care date; therapy necessity, effectiveness, and goals; mental status; services and equipment; visit frequency; prognosis; rehabilitation potential; and functional limitations.
Activities permitted; nutritional requirements; medications and treatments; safety measures; timely discharge or referral instructions; and other relevant information.

Documentation Required

Document Caregivers and Other Resources

Document all paid and nonpaid resources relevant to the requested hours, including caregiver availability, schedules, travel time, treatment time, other services, and multiple-member household situations.

Report each nonpaid caregiver, even when the number is zero, and identify work, school, childcare, physical limitations, and availability.
Include member work or school schedules, other home health services, treatment hours and visits, and the number of household members receiving home health services.
Include a signed cost estimate for each requested service plus overhead for the requested period.

Documentation Required

Provide Employment Verification

For each employed nonpaid parent or caregiver, provide current employment verification. The documentation must substantiate the schedule, including overtime or irregular hours.

Use a company-letterhead confirmation signed by a manager, supervisor, or HR representative, or a company email from a supervisor with contact information.
Self-employed caregivers must sign their own letter.
If a confirmation letter cannot be obtained, submit the two most recent months of paystubs.

Documentation Required

Provide School Verification

For each nonpaid parent or caregiver attending school, submit an official or unofficial transcript and/or class schedule supporting the dates and times of unavailability.

Include institution name and contact information, class times and locations, in-person travel time, and instructor office hours when needed.
If the caregiver works while attending school, submit both employment and school documentation.

Documentation Required

Support Skilled Services Clinically

For skilled services, document a written order within the practitioner’s scope, personal member evaluation, practitioner involvement, medical necessity, and a current plan of care with progress notes. Services must be member-specific and available for postpayment audit.

Nursing documentation must address the necessity and effectiveness of services.
Therapy documentation must identify the ordered procedures, modalities, amount, frequency, and duration.

Billing Rule

Bill Nurse-Performed Aide Services Correctly

If a home health aide cannot be contracted and a skilled nurse performs aide duties, document what the nurse performed and bill the appropriate home health aide code. Do not bill skilled nursing codes for aide services.

Postpayment review may recoup an overpayment when aide services are billed as skilled nursing.

Documentation Required

Capture Required EVV Data

Home health providers must use EVV for all members under both FFS and managed care. EVV records must contain the service, member, date, location, worker, and start and end times.

Service type performed.
Member identity, including IHCP Member ID and associated Payer ID.
Date and location of service delivery.
Identity of the individual providing the service.
Service start and end times.

Billing Rule

Complete Line-Item Claim Information

Report each date of service as a separate claim line and each level of service provided on that date as a separate line. Every line must include the applicable HCPCS/CPT procedure code, modifiers when needed, date of service, revenue code, and units.

Applicable revenue-code pairings include 552 with 99600 TD or TE, 559 with 99601 or 99602, and 572 with 99600.
Therapy codes use 15-minute units; nursing, aide, LPN, and RN services use one-hour units.

Unsupported block type: billing_rule

Documentation Required

Complete EVV Enrollment and Training

Agencies using the state-sponsored Sandata EVV solution must complete self-paced training and submit the completion certificate with the IHCP Provider ID. Agencies using an alternate system must register online and ensure federal compliance.

Send the certificate and Provider ID to inxixevv@gainwelltechnologies.com.
Alternate systems must transmit all required EVV fields to the Sandata aggregator.

Denial Risk

No Billable Service Rendered

Do not bill services when the member refuses or when the therapist, aide, LPN, or RN does not render a service. Refused or nonperformed services produce no payable units and no payable overhead.

A provider may report overhead only when an encounter occurred.
One overhead charge is permitted per provider, member, and day.

Denial Risk

Do Not Bill for No Service

Bill only services actually rendered and do not submit separate billing for a member refusal, absent service, or nonperformance by a therapist, aide, LPN, or RN.

If no service is rendered, IHCP does not reimburse the service or related overhead.

Denial Risk

Avoid Duplicate Same-Day Billing

Do not submit separate claim lines or claims for the exact same service and date of service. Duplicate same-day billing is subject to exact-duplicate denial.

Multiple visits of the same service on one day must be combined on one claim detail with total units.

Denial Risk

Validate the Plan-of-Care Signature

Use a valid original, stamped, or permitted electronic signature on the PA form and state forms. The plan of care must be clearly signed by a practitioner within the applicable scope of practice.

Electronic, typed, or stamped signatures on supporting documents must match the written plan-of-care signature.
An invalid, missing, or mismatched signature can invalidate the PA documentation.

Denial Risk

Consolidate Duplicate Same-Day Service Lines

Do not split identical same-day services across separate claim details. Combining multiple visits of the same service on one detail prevents exact-duplicate denials.

Different service levels, such as RN and LPN, may be reported as separate lines when each is appropriately coded and provided.

Billing Rule

Follow Multiple-Visit Billing Rules

For multiple visits of the same prior-authorized service on one day, bill all visits on the same claim form and one detail using the total units. Separate claims or details may cause one or more services to deny as duplicates.

Additional paid hours require a paid claim adjustment.
Rotating personnel merely to increase billing is not appropriate.

Denial Risk

Use the Correct EVV Payer ID

Select the correct EVV Payer ID for each member so EVV records match claims. For FFS members use INFSSA; each managed care entity has its own Payer ID.

An incorrect Payer ID prevents matching and can result in claim denial.

Denial Risk

Use Supported, Properly Rounded Units

Do not bill partial units. Apply the required whole-unit and therapy rounding rules only when a service was actually provided.

Therapy: 15 minutes equals one unit; eight or more minutes may be rounded to a unit, but less than eight minutes is not billable.
Aide, LPN, and RN services: fewer than 29 minutes may be billed as the first hour only when service was provided; after the first hour, round 30 or more minutes up and 29 or fewer minutes down.

Denial Risk

Do Not Unbundle Supplies or Bill Without a Home Encounter

For daily infusion therapy billed with 99601 or 99602 and revenue code 559, supplies are bundled into the daily rate and no separate supply billing is permitted. Do not bill overhead when the daily service did not include an actual home encounter.

Only one unit of service may be billed daily.
Included costs include the home uterine monitor, skilled nursing components, monitoring support, and electronic transmission costs.

Develops and reviews the member's written plan of care every 60 days

Face-to-face encounter

Qualifying encounterAn encounter with the certifying practitioner for certification or recertification of home health need

Permitted formatIn person or through compliant telehealth

Required timingAt initiation, after an interruption of 60 days or more, and on a rolling annual basis for long-term services

Interruption of home health services

DefinitionAn interruption is 60 days or more from the end of the last authorization period

Certification consequenceA face-to-face encounter is required after this interruption

Measurement pointThe period is measured from the end of the last authorization period

Special situation

DefinitionA situation in which a member may receive up to 16 hours per day of ongoing skilled care

EvaluationThe individual situation must be evaluated through a prior authorization request

ExamplesQualifying circumstances include caregiver work, caregiver disability or significant additional childcare responsibilities

Significant childcare responsibilities

First thresholdThree or more children under age 6

Alternative thresholdFour or more children under age 10

Special medical needsOne or more children requiring extensive medical and physical care beyond the needs of an average well child

Multiple-member care situation

DefinitionMore than one member of a single household receives home health services

Care coordinationCare must be coordinated in the most efficient manner

ReportingThe situation must be reported on each member's individual prior authorization request

Enteral therapy

RouteFeeding within or by way of the intestine

Tube deliveryNutritional requirements may be delivered through a tube into the stomach or small intestine

Service categoryEnteral feeding is included in home infusion therapy

Parenteral therapy

DefinitionTherapy administered by a route other than the alimentary canal

Included routesIntravenous, subcutaneous, intramuscular or mucosal routes

Service categoryParenteral therapy is included in home infusion therapy

TPN

MeaningTotal parenteral nutrition therapy

Administration categoryParenteral therapy

Home infusion classificationTPN is included among home infusion services

EVV

DefinitionAn electronic visit verification system used to document home health services rendered

Required scopeRequired for home health services for all members, including fee-for-service and managed care members

Required recordsType of service, member and IHCP Member ID, payer ID, service date, location, individual providing service, and service start and end times