CurrentmhnPolicy N/A

Authorization Guide for Personal Care and Homemaker Services (PCHS)

Governs authorization, eligibility, documentation, coordination, and billing for short-term Personal Care and Homemaker Services to help members remain safely in their homes; applies to providers and members in North Carolina noted in the document.

Policy Summary

Payermhn

PolicyPersonal Care and Homemaker Services (PCHS) — authorization, eligibility, documentation, coordination, and billing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with the Community Supports (CS) PCHS Authorization Form and request initial authorization for up to 60 days; if IHSS denial, a one-time 60-day authorization may be granted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysmaximum initial authorization duration

One-time 60-dayIHSS-denial special authorization

15 minbilling increment (T1019 U6)

>=8 minRule of Eights minimum

Coverage Criteria — Personal Care and Homemaker Services (PCHS)

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Covered scenarios

Covered when ANY of the following scenarios apply (subject to documentation and authorization limits):

Coverage scenarios: 1) During the IHSS application process, including any waiting period after a referral; PCHS may be approved before IHSS services begin. 2) As supplemental support when IHSS hours are insufficient or exhausted. 3) For IHSS-ineligible individuals to prevent short-term skilled nursing facility stays (up to 60 days).

Requests for short-term PCHS must document risk of institutionalization and coordinate to avoid duplication with HCBA/WPCS.

Eligibility

Eligibility criteria (members must meet at least one):

Eligibility: Member is at risk of hospitalization or institutionalization in a nursing facility; OR has functional impairment and lacks adequate support; OR is approved for IHSS.

Eligibility criteria reference IHSS program guidance (see IHSS eligibility resources).

Authorization limits and reassessment

Authorization duration and extension logic:

Initial and extension rules: Initial authorization is based on assessed need with a maximum duration of 60 days.maximum 60 days

Prior authorization required; initial approvals tied to documented assessed need.

IHSS-denial special authorization: If IHSS denies eligibility, a one-time 60-day authorization may be granted; no further extensions are allowed for that IHSS-denial authorization.one-time 60 days

No extensions permitted for the one-time IHSS-denial authorization.

Continued need and reassessment: For other continuing needs, submit a reassessment and request extensions in 30-day increments until IHSS is approved, a caregiver is identified, or alternative care is arranged.30-day extension requests

Failure to submit timely reassessments may result in termination of authorization; PCHS cannot replace IHSS referrals and eligible members must be referred to IHSS.

Individuals who are currently receiving Waiver Personal Care Services (WPCS) through the Home and Community Based Alternatives (HCBA) waiver are not eligible for Personal Care and Homemaker Services (PCHS). PCHS may be provided to members who are on the HCBA waitlist until waiver approval, but providers must manage HCBA WPCS separately to avoid duplication of services.

PCHS is intended to supplement or bridge to IHSS and HCBA waiver services, not to replace them. Requests for PCHS must document the need and cannot be used as a substitute for an IHSS referral; eligible members must be referred to IHSS. When IHSS hours are insufficient, PCHS may be authorized as supplemental support, and when IHSS denies a request a one-time 60-day authorization may be granted with no extensions permitted. For continuing needs other than IHSS denial, providers must submit timely reassessments and request extensions every 30 days until IHSS approval, a caregiver is identified, or an alternative care arrangement is made.

Coding and Billing

Covered HCPCSHCPCSCovered

T1019 U6

Per 15 minutes

inv-07: Rule of Eights billing minimum

Minimum billable timeAt least eight minutes of treatment required to bill the first 15-minute increment; the same eight-minute minimum applies for each subsequent 15-minute increment.

Applies to codeT1019 U6 (per 15 minutes)

Billing practiceProviders must document minutes of service to support each 15-minute increment billed in compliance with the Rule of Eights.

Increment length15-minute billing increments.

Provider Actions, Authorization & Coordination

Prior Authorization

Prior Authorization Required

Prior authorization is required for Personal Care and Homemaker Services (PCHS). Initial authorizations are based on the documented assessment of member need and are limited to a maximum duration of 60 days.

Initial authorization: up to 60 days based on assessed need
PCHS may be authorized during IHSS application, as a supplement to IHSS, or for IHSS-ineligible individuals to avoid short-term institutionalization

Documentation Required

Required Authorization Form

Requests for PCHS must include the Community Supports (CS) Personal Care and Homemaker Services Authorization Form. The form must contain the assessment of member needs that supports the authorization request.

Required form: Community Supports (CS) Personal Care and Homemaker Services Authorization Form
Form must include: documentation of assessment and justification for requested services

Denial Risk

Extension Limitations

Extension rules vary by circumstance. A one-time 60-day authorization issued because of an IHSS denial cannot be extended. For other situations, providers must submit a timely reassessment and request extensions in 30-day increments until IHSS approval, a caregiver is identified, or an alternative care arrangement is in place.

IHSS denial: one-time 60-day authorization — no extensions allowed
Other needs: reassessment and request required every 30 days for continued authorization
Providers must refer eligible members to IHSS; PCHS supplements or bridges to IHSS/HCBA and should not duplicate IHSS or WPCS services

Definitions

inv-13: ADLs and IADLs

Activities of Daily Living (ADLs)Personal self-care tasks such as bathing, dressing, toileting, ambulation, feeding, grooming, and bowel/bladder care.

Instrumental Activities of Daily Living (IADLs)More complex activities needed for independent living such as meal preparation, grocery shopping, and money management.

Additional examplesHousekeeping (cleaning, laundry) and accompaniment to medical appointments may support ADL/IADL needs.

Support purposeServices assist individuals to remain safely in their homes and may include supervision for cognitive or mental impairments.

Background

The purpose of Personal Care and Homemaker Services (PCHS) is to provide short-term assistance with Activities of Daily Living (ADLs) and Instrumental ADLs so members can remain safely in their homes. Services include personal care, housekeeping, meal preparation, shopping assistance, accompaniment to appointments, and supervision for cognitive or mental impairment. PCHS may be authorized to prevent hospitalization or institutionalization, to bridge gaps while members apply for or wait for IHSS or HCBA waiver services, or to supplement IHSS when authorized hours are insufficient.