CurrentKaiser PermanentePolicy 01-38

Review Criteria Georgia Region

Defines medical necessity criteria, indications, and documentation requirements for coverage of home health skilled services and home health aide services for Kaiser Permanente Georgia Region, aligned to Medicare guidelines.

Policy Summary

PayerKaiser Permanente

PolicyReview Criteria Georgia Region

Policy CodePolicy 01-38

Change TypeReviewed/Revised

Effective DateJun 21, 2006

Next Review Date

Key ActionPhysician must create and periodically review a plan of care and must have had a virtual or in-person visit with a physician/advanced practitioner within 90 days of starting home health care.

POLICY UPDATE CHANGES

Document reviewed/revised; last revision date 8/8/24 per header.

2Covered Service Categories (Skilled services; Home health aide services)

7Key coverage criteria items

Coverage Summary

Policy Number: 01-38. Coverage stance: Covered with criteria. This policy defines medical necessity criteria, indications, and documentation requirements for coverage of Home Health Skilled Services and Home Health Aide Services for Kaiser Permanente Georgia Region and is aligned with Medicare guidelines. Effective date: 2006-06-21. Last review: 2024-08-08.

Thresholds

Intermittent skilled nursing definitionFewer than 7 visits per week; less than 8 hours per day; 35 hours or less per week; for periods of 21 days or less

Physician visit prior to starting home health carePhysician/advanced practitioner must have had a virtual or in-person visit within 90 days of starting home health care

Patient must be under physician careThe patient is under the care of a physician and the physician has created and periodically reviews a plan of care

Home confinement requirementPatient is confined to the home with inability to leave without considerable and taxing effort; absences infrequent, short, and usually for health care

Medical-Necessity Criteria

Home Health Skilled Services - Indications

Home Health Skilled Services are covered when ALL of the following criteria are met:

ALL of the following

Home confinement details
- There is an inability to leave the home without considerable and taxing effort
- Absences from the home are infrequent
- Absences from the home are for relatively short periods of time
- Absences from the home are to receive health care treatment
- Patient does not have to be bedridden
The service is medically necessary
The patient is under the care of a physician
The physician has created a plan of care and periodically reviews that planvirtual or in person visit within 90 days of starting home health care
Must have had a virtual or in person visit with a physician/AP within 90 days of starting home health care.
The patient is in need of skilled nursing care on an intermittent basis, or physical therapy or speech therapy or has a continuing need for occupational therapy
Intermittent skilled nursing definition: Intermittent is defined as skilled nursing care provided or needed on fewer than 7 visits per week, less than 8 hours per day and 35 hours or less per week and for periods of 21 days or lessfewer than 7 visits/week; <8 hours/day; ≤35 hours/week; ≤21 days
Defined intermittent skilled nursing.
The Home Health Vendor has supplied the Oasis score

Home Health Aide Services - Indications

Home Health Aide Services are covered when ALL of the following are met:

ALL of the following

Prerequisite: Patient meets all of the Home Health Skilled Services criteria above
Reference: patient must meet skilled services criteria
The services are intermittent as defined above and do not exceed the number of skilled visitsIntermittent: fewer than 7 visits/week; <8 hours/day; ≤35 hours/week; ≤21 days
Home health aide services must be intermittent and not exceed skilled visit count
The services must be reasonable and necessary to the treatment of the patient's illness or injury
There is no one else who is able and willing to act as the patient's caregiver

Home Health Aide Services - Permitted Activities

Home health aide services may include but are not limited to:

ANY of the following

Personal care: bathing, dressing, grooming etc to facilitate treatment or to prevent deterioration of the patient's health
Feeding and ADLs: Feeding, assistance with elimination, ambulation, changing position in bed, transfer assists, routine maintenance exercises, ST exercises, care of prosthetics and orthoptics
Support: All in direct support of overall treatment

Provider Actions & Documentation Requirements

Documentation Required

Physician plan of care and visit requirement

Physician must create and periodically review a plan of care and must have had a virtual or in-person visit with a physician/advanced practitioner within 90 days of starting home health care.

Documentation Required

OASIS score submission

The Home Health Vendor must supply the OASIS score to the payer (Home Health Vendor has supplied us with the Oasis score).

Billing Rule

Home health aide visit limits

Home health aide services must be intermittent as defined for skilled nursing (fewer than 7 visits per week; less than 8 hours per day; 35 hours or less per week; for periods of 21 days or less) and must not exceed the number of skilled visits.

Background & Evidence

This policy follows Medicare guidelines for determining approval of skilled services and home aide services in the home. It references and aligns with Medicare rules and regulations and specifically cites the Medicare Benefit Policy Chapter 7 as a guiding source for benefit determinations and coverage decisions used by Quality Resource Management staff. The document is maintained by the Georgia Region Utilization Management committee and reflects Medicare-aligned criteria for home confinement, skilled services, and aide services.

Primary references supporting the criteria include Medicare rules and regulations (CMS website) and Medicare Benefit Policy, Chapter 7 (listed in references). The policy explicitly states that Medicare guidelines are followed for determination of approval for skilled services and aide services in the home and lists Medicare rules/regulations and Medicare Benefit Policy Chapter 7 among its primary references.

99500-99507
99509
99601-99602
S9123-S9124
S9128
S9152
S9131

OpenPayer

Review Criteria Georgia Region

Coverage Summary

Medical-Necessity Criteria

Provider Actions & Documentation Requirements

Coding

Background & Evidence

Definitions

Medicare Determinations

Revision History