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    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceKaiser Permanente Advanced Care at Home Coverage |…
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    CurrentKaiser PermanentePolicy N/A

    Advanced Care at Home (ACAH) — Coverage Criteria

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    Defines clinical review criteria, coverage requirements, services, and limitations for Kaiser Permanente Advanced Care at Home (ACAH) for Medicare and non‑Medicare members within the plan's service area.

    Policy Summary
    PayerKaiser Permanente
    PolicyAdvanced Care at Home (ACAH) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeCost-sharing alignment
    Effective DateJan 1, 2025
    Last ReviewJan 1, 2025
    Next Review Date
    Key ActionObtain preauthorization for Advanced Care at Home and document referral, inpatient medical necessity per MCG, member consent, ED proximity (within 30 minutes), and cell service.
    SourceLink
    POLICY UPDATE CHANGES

    Updated cost-sharing rules to follow standard cost-sharing based on the type of service billed by qualified providers, with a 60-day notice and effective date 01/01/2025.

    30 daysmax ACAH episode (acute + restorative)
    30 minmax ground travel time to ED

    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.

    24/7
    medical command center
    cell servicecare location connectivity
    Medically Homenetwork provider

    Coverage Criteria

    Eligibility criteria

    Covered when ALL of the following are met

    Referral: Member is referred into the advanced care program by the managing provider (e.g., from an emergency department).
    Preauthorization is obtained based on the member's health status, treatment plan, and home setting or another appropriate care location within the service area.
    Medical necessity: The clinical condition meets inpatient medical necessity criteria per MCG inpatient hospitalization guidelines appropriate to the patient's clinical condition.
    Consent: Member consents to receiving advanced care as described in the treatment plan.
    Care location proximity: Care location (e.g., the member's residence) is within 30 minutes ground travel time of an emergency department.within 30 minutes
    Connectivity: Care location must have cell service.

    Services are limited to those specified in the member's Advanced Care at Home treatment plan. The following are explicit exclusions: Private duty nursing; housekeeping or meal services not part of the Advanced Care at Home treatment plan; any care provided by or for a family member; and any other services rendered in the home which are not specified in the member's Advanced Care at Home treatment plan.

    Advanced Care at Home is covered when all of the following are met: the member is referred into the program by the managing provider; preauthorization has been obtained based on the member's health status, treatment plan, and home setting; the clinical condition meets inpatient medical necessity per MCG inpatient hospitalization guidelines; the member has provided consent to the treatment plan; the care location is within 30 minutes ground travel time of an emergency department; and the care location has functioning cell service.

    Providers must verify authorization requirements for specific billing using the Pre-authorization Code Check and document the managing provider referral, evidence that the clinical condition meets inpatient medical necessity per MCG inpatient hospitalization guidelines, member consent, care location proximity to an ED, and cell service availability when submitting authorization requests.

    Coding and Operational Limits

    Applicable codes and authorization checkmixed
    No codes listed
    Care location ED proximity — within 30 minutes ground travel time
    Maximum allowed ground travel time to EDCare location must be within 30 minutes ground travel time of an emergency department.
    ApplicabilityApplies to the member's residence or other appropriate care location used for Advanced Care at Home.
    ContextRequirement is part of the eligibility criteria all members must meet to receive Advanced Care at Home.

    Provider Actions and Authorization

    Prior Authorization

    Preauthorization required — confirm via Code Check

    Advanced Care at Home requires preauthorization. Verify whether specific billing codes require authorization using the Pre-authorization Code Check, since member contracts and plan types may vary.

    • Preauthorization is required based on the member's health status, treatment plan, and home setting or another appropriate care location within the service area.
    • Use the Pre-authorization Code Check to confirm authorization requirements for specific codes by plan type.
    Note

    Provider responsibilities — referrals, consent, and care location

    The managing provider must refer the member into the Advanced Care at Home program and ensure the treatment plan and home setting meet program criteria before services begin.

    • Arrange referral into the advanced care program (for example, from an emergency department).
    • Confirm the member provides consent to receive advanced care as described in the treatment plan.

    Background

    Advanced Care at Home is a patient-centered program that delivers acute and restorative care in the member's residence or another appropriate setting for certain clinical conditions. Services must be associated with an acute episode; the combined acute and restorative episode is limited to 30 days. Availability of the program depends on geography and the member's contract benefit design, and the care location must be within 30 minutes ground travel time of an emergency department and have cell service.

    Definitions

    Episode duration — combined acute and restorative phases limited to 30 days
    Episode duration limitThe combined acute and restorative phases of care are limited to a total of 30 days.
    ScopeApplies to a single episode of Advanced Care at Home, including both acute treatment and any associated restorative care.
    Program linkageEpisodes must be associated with an acute episode and the restorative phase must be part of the same treatment plan.
    Care location eligibility — residence must be within 30 minutes ground travel time and have cell service
    ED proximity requirementCare location (e.g., member residence) must be within 30 minutes ground travel time of an emergency department.
    Connectivity requirementCare location must have cell service to support communication with the medical command center.
    Policy Summary
    PayerKaiser Permanente
    PolicyAdvanced Care at Home (ACAH) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeCost-sharing alignment
    Effective DateJan 1, 2025
    Last ReviewJan 1, 2025
    Next Review Date
    Key ActionObtain preauthorization for Advanced Care at Home and document referral, inpatient medical necessity per MCG, member consent, ED proximity (within 30 minutes), and cell service.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Operational LimitsProvider Actions and AuthorizationBackgroundDefinitions
  1. Ensure the care location is within required proximity and connectivity (see documentation requirements).
    2. Documentation Required

    Required documentation for authorization

    Include clinical and logistical evidence with preauthorization requests: referral source, documentation that the clinical condition meets inpatient medical necessity per MCG guidelines, member consent, and verification of care location proximity and connectivity.

    • Document referral by the managing provider (e.g., emergency department referral).
    • Provide evidence that the clinical condition meets inpatient medical necessity per MCG inpatient hospitalization guidelines appropriate to the patient's condition.
    • Include member consent to the Advanced Care at Home treatment plan.
    • Verify and document that the care location is within 30 minutes ground travel time of an emergency department and has cell service.
    • If applicable, note any specific codes and whether they require authorization using the Pre-authorization Code Check.
    Denial Risk

    Denial risk if preauthorization not obtained

    Failure to obtain preauthorization may lead to denial of Advanced Care at Home services if the member's health status, treatment plan, or home setting do not meet program requirements.

    • Preauthorization is required based on the member's health status, treatment plan, and home setting; lack of required authorization may trigger denial.
    PurposeRequirements ensure timely access to emergency services and reliable communications for 24/7 medical command center support.