CurrentKaiser PermanentePolicy N/A

Home Health Skilled Services and Home Health Aide Services — Coverage Criteria

Defines medical necessity criteria for coverage of home health skilled services and home health aide services for Kaiser Permanente members in the Georgia region; applies to Quality Resource Management staff and Home Health vendors involved in authorization decisions.

Policy Summary

PayerKaiser Permanente

PolicyHome Health Skilled Services and Home Health Aide Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeReviewed/Revised

Effective DateJun 21, 2006

Next Review DateN/A

Key ActionObtain prior authorization from Quality Resource Management and ensure the Home Health Vendor supplies the OASIS score and a physician-created plan of care with a physician/AP visit within 90 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤35 hrs/wkIntermittent skilled nursing

≤90 daysPhysician visit recency

OASIS requiredOASIS requirement

CPT/HCPCS groupService codes

Coverage Criteria for Home Health Services

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Initial Home Health Skilled Services

Covered when ALL of the following are met:

Homebound status

Homebound components: There is an inability to leave the home without considerable and taxing effort; absences from the home are infrequent; absences are for relatively short periods of time; absences are to receive health care treatment; patient need not be bedridden; the service is medically necessary
Refer to policy section 4.1.1 - 4.1.1.6

Physician oversight: The patient is under the care of a physician and the physician has created and periodically reviews a plan of carePhysician/AP visit within 90 days of starting home health care

Must have had a virtual or in-person visit within 90 days

Skilled service need: The patient is in need of skilled nursing on an intermittent basis, or physical therapy, or speech therapy, or has a continuing need for occupational therapyIntermittent defined for skilled nursing: fewer than 7 days/week; <8 hours/day; ≤35 hours/week; periods ≤21 days

See intermittent skilled nursing definition in policy

OASIS and authorization: Home Health Vendor has supplied the OASIS score and services are authorized by the Home Health Review Nurse

Documentation requirement

Home Health Aide Services

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

Meet skilled criteria: Patient meets all Home Health Skilled Services criteria

Refer to Initial Home Health Skilled Services criteria

Intermittent and visit limits: Services are intermittent as defined for skilled nursing and do not exceed the number of skilled visitsIntermittent definition applies

Aide visits limited to skilled visit levels

Necessity and capability: Services are reasonable and necessary to the treatment of the patient's illness or injury and are of a type the patient cannot perform themselves

No available caregiver:

Covered when ALL of the following are met: the member is homebound (confined to the home with inability to leave without considerable and taxing effort; absences are infrequent, short, and generally for health care; patient need not be bedridden), the member is under the care of a physician, and the physician has created and periodically reviews a plan of care with a physician/AP visit within 90 days of starting home health care. The member must need skilled nursing on an intermittent basis, physical therapy, speech therapy, or continuing occupational therapy. For skilled nursing, intermittent is defined as care provided or needed on fewer than 7 days per week; less than 8 hours per day; ≤35 hours per week; and for periods of ≤21 days. The Home Health Vendor must supply an OASIS score and services must be authorized by the Home Health Review Nurse.

Services are considered not medically necessary when the conditions above are not met — for example, when the member is not homebound, is not under physician care, lacks a physician-established plan of care with the required physician/AP visit within 90 days, or when services exceed the defined intermittent limits. Additionally, Home Health Aide services are only covered when they meet the skilled criteria, are intermittent and do not exceed the number of skilled visits, are reasonable and necessary, the member cannot perform them, and there is no available caregiver; failure to meet these requirements may result in denial.

Provider Actions, Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Home Health services require prior authorization. All Home Health Skilled Services and Home Health Aide services must be authorized by the TSPMG Home Health Review Nurse through the Home Health review process managed by Quality Resource Management before services begin.

Authorization required from Quality Resource Management/TSPMG Home Health Review Nurse
Home Health Vendor must supply the OASIS score as part of authorization materials

Documentation Required

Documentation Required for Authorization

The Home Health Vendor must provide required documentation to support authorization and ongoing coverage. A physician-established plan of care must exist and be periodically reviewed; the vendor must supply the OASIS score to the reviewer.

OASIS score provided by Home Health Vendor
Physician-created plan of care with a virtual or in-person physician/AP visit within 90 days of starting home health care

Denial Risk

Denial Triggers

Services may be denied if coverage criteria are not met. Key triggers for denial include the patient not meeting the definition of homebound, lack of physician care or an absent/untimely physician-established plan of care, and failure to provide required documentation such as the OASIS score.

Patient not homebound (no considerable and taxing effort to leave home; absences frequent or prolonged)
Patient not under the care of a physician
No physician-established plan of care or no physician/AP visit within 90 days of starting home health
Required OASIS score not supplied by Home Health Vendor
Services not skilled, not intermittent as defined, or not medically necessary

Note

Provider Action / Alert

Providers should confirm authorization and ensure all documentation is submitted timely to avoid delays or denials. Contact the TSPMG Home Health Review Nurse or Quality Resource Management with questions about the review process or required materials.

Background

Home health skilled services and home health aide services support members who are homebound and require intermittent skilled nursing, physical therapy, speech therapy, or ongoing occupational therapy. Coverage determinations follow Medicare-style criteria and depend on the member's clinical need, physician oversight with a documented plan of care, and documented functional status supplied by the Home Health Vendor (including the OASIS score). Home Health Aide services provide personal care and assistance (bathing, dressing, feeding, ambulation, transfers, routine exercises, care of prosthetics) when such tasks are necessary to treat the illness or prevent deterioration and cannot be performed by the patient or an available caregiver.

99500-99507	99500-99507
99509	99509
99601-2	99601-2
S9123-24	S9123-24
S9128	S9128
S9152	S9152
S9131	S9131

OpenPayer

Home Health Skilled Services and Home Health Aide Services — Coverage Criteria

Coverage Criteria for Home Health Services

Coding, Definitions, and Service Indicators

Provider Actions, Authorization, and Denial Triggers

Background

Key Definitions