CurrentMass General Brigham Health PlanPolicy N/A

Home Health Care reimbursement

Defines Mass General Brigham Health Plan reimbursement rules for contracted home health care agencies, describing covered and non-covered services, coding and billing guidance, and authorization expectations for members under the Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyHome Health Care reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateJan 1, 2025

Key ActionRefer to MGBHP Prior Authorization/Notification and Referral Guidelines; skilled nursing visits started on non-business days do not require prior authorization until the next business day.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2early maternity discharge skilled nursing visits allowed

35max hours per week

Jan 1, 2023telehealth reporting start

Jul 1, 2023telehealth G-codes required

299501 visit maximum

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Rules

Coverage criteria and rules

Mass General Brigham Health Plan reimburses the following home health services when billed by an appropriate contracted provider; services excluded are listed separately. Authorization and billing rules follow.

ALL of the following

Covered services (one or more of)
- Medical supplies and/or DME obtained by a Mass General Brigham Health Plan participating DME provider
- Intermittent skilled nursing: RN or LPN
- Medical social services
- Nutritional counseling when considered a medically necessary component of skilled home health care services
- Services of a home health aide when considered a medically necessary component of an active skilled home care program
- Physical, speech, and occupational therapies
- Physician and nurse practitioner services billed by a contracted Mass General Brigham Health Plan provider
- Two early maternity discharge skilled nursing visits (limit: 2 visits)
  See maximum visit limits; CPT 99501 limited to 2 visits maximum
- PT/OT visits reimbursed up to the maximum visits allowed as defined by the member's plan
Excluded services (none may be billed as covered)
- Companion services
- Custodial care services
- Domestic housekeeping services
- Home health aide services in the absence of an active skilled home care program
- Homemakers
- Meal service
- Medical supplies which are inclusive to the home health visit payment
Billing and authorization rules
- Telehealth G-codes voluntary reporting begins Jan 1, 2023; required on claims July 1, 2023; report on Type of Bill 032X with specified revenue codes
- Report remote patient monitoring spanning multiple days as a single line item with start date and number of days; document how technology supports plan of care goals
- Append modifier SL for state‑supplied vaccines in primary modifier field; bill vaccine administration on a separate line
- When billing PT/OT services rendered by a PT/OT assistant, submit modifier 52 (reduced services)
- Referral/prior authorization required for various services; skilled nursing visits initiated on non‑business days do not require prior authorization until the next business day
  See MGBHP Prior Authorization/Notification and Referral Guidelines for specifics

Service Codes and Billing Limits

Home health service codesmixed

0424	Physical Therapy Evaluation
0421	Physical Therapy Visit
0434	Occupational Therapy Evaluation
0431	Occupational Therapy Visit
0444	Speech Therapy Evaluation
0441	Speech Pathology Visit
0551	Skilled Nursing Service
0561	Medical Social Service
0572	Home Health Aide Service
99501	Home visit for postnatal assessment and follow up care (2 visit maximum)

1–10 of 12

1/2

Telehealth home health G-codesCPT

G0320	Home health services furnished using synchronous telemedicine (audio/video)
60321	Home health services via telephone or audio-only interactive system
60322	Collection of physiologic data digitally stored/transmitted by patient (remote patient monitoring)

inv-04: 99501 visit limit

Maximum visits for CPT 995012 visits maximum

Code99501

DescriptionHome visit for postnatal assessment and follow up care

Prior Authorization, Referrals, and Provider Requirements

Prior Authorization

Prior Authorization and Referral Required

Some services and procedures require a referral and/or prior authorization. Refer to the Mass General Brigham Health Plan Prior Authorization and Referral Guidelines for details on which services need authorization and how to submit requests. Note: skilled nursing visits that are initiated on non‑business days do not require prior authorization until the next business day.

See MGBHP Prior Authorization and Referral Guidelines for full submission instructions and contact information.
Skilled nursing visits started on weekends/holidays: prior authorization not required until next business day.

Key Definitions

inv-06: Home Health Care

DefinitionCare rendered by a contracted home health care agency to a member confined to home due to illness, injury, or disability who cannot leave home without considerable and taxing effort, or when home is determined to be the most appropriate setting by an MGBHP care manager.

SettingMember's place of residence when home is the most appropriate setting as determined by Mass General Brigham Health Plan care manager.

Reimbursement noteCovered services and reimbursement are defined by the member's benefit plan and provider agreement with Mass General Brigham Health Plan.

inv-07: Home Health Care Services

ScopeLimited part-time or intermittent skilled nursing care and home health aide services defined as fewer than eight hours per day on a less-than-daily basis, up to 35 hours per week.

Included servicesPhysical therapy, occupational therapy, speech therapy, medical social services, durable medical equipment, and medical supplies.

Exclusion noteHome health aide services are covered when part of an active skilled home care program (see coverage criteria for exclusions).

inv-08: Skilled Nursing Service

DefinitionPlanning, provision, and evaluation of goal-oriented nursing care that requires specialized knowledge and skills acquired through an approved nursing curriculum.

Provider skill requirementServices include only those that require the skills of a nurse (RN or LPN).

Relation to billingSkilled nursing services are coded (e.g., 0551) and billed per provider agreement and policy guidelines.