CurrentmhnPolicy N/A

Short-Term Post-Hospitalization Housing (STPHH) — Coverage Criteria

Defines eligibility, documentation, authorization, limits, billing code, and provider requirements for short-term post-hospitalization housing services for members exiting inpatient or residential facilities in North Carolina (NC).

Policy Summary

Payermhn

PolicyShort-Term Post-Hospitalization Housing (STPHH) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a Short-Term Post-Hospitalization Housing Referral Form with required supporting documentation to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-daypresumptive authorization period

Up to 90 daysinitial authorization duration

6 monthsmaximum combined Room & Board services per rolling 12 months

H0043 U3billing code and modifier

Coverage & Eligibility

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.

Eligibility criteria for STPHH

Covered when ALL of the following are met:

Entry requirement: Individual is exiting an institution (recuperative care facility, inpatient hospital — acute or psychiatric or Chemical Dependency and Recovery hospital, residential substance use disorder or mental health treatment facility, correctional facility, or nursing facility).

Housing risk: Individual is experiencing or at risk of homelessness (meets HUD definition with specified modifications for exiting institutions and extended imminent loss timeframe).

Clinical qualifying conditions: Member meets one or more of: receiving Enhanced Care Management; has one or more serious chronic conditions; has serious mental illness; is at risk of institutionalization or requiring residential services due to a substance use disorder.

Ongoing needs: Has ongoing physical or behavioral health needs as determined by a qualified health professional that would otherwise require continued institutional care if not for receipt of STPHH.

Not eligible for Short-Term Post-Hospitalization Housing (STPHH) if the member has already exhausted the combined six-month / 182-day global cap for Room & Board services within the rolling 12-month period. Providers should confirm prior authorizations and remaining days in the provider portal before submitting authorization requests; claims for members who have exhausted the 182-day limit will not be reimbursed.

Admission Criteria

residential (admission) — 1 top-level node

Admission to STPHH: Member is exiting an institutional stay AND is experiencing or at risk of homelessness AND meets one or more clinical qualifying conditions AND has ongoing physical or behavioral health needs that would otherwise require continued institutional care.

Continued Stay Criteria

residential (continued stay) — 1 top-level node

Continued stay authorization: Reassessment by a licensed professional documenting ongoing need must be submitted for reauthorization; extensions may be approved up to the remaining days within the service limit (total combined Room & Board services limited to six months/182 days per rolling 12-month period).

Service Day Limits

inv-18: residential — 182 calendar days (6 months) per rolling 12-month period

Service maximum (global cap)182 calendar days (6 months) per rolling 12-month period

Applies across servicesCombined cap covers Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent (Room & Board services)

Provider responsibilityProviders must confirm prior authorizations and remaining days in the provider portal before submitting authorization

inv-19: residential — 7 days (presumptive authorization period)

Presumptive authorization period7 days (service may begin pending plan approval, submission of required documentation, and confirmation of cap eligibility)

ContingencySubject to the Plan's approval of eligibility and required documentation

Reimbursement riskIf authorization is denied, the presumptive authorization period is ineligible for reimbursement

inv-20: residential — Up to 90 days (initial authorization duration)

Initial authorization durationUp to 90 days (based on individual needs)

Reauthorization requirementReassessment by a licensed professional must be submitted for extensions; extensions allowed up to remaining days in the service limit

Subject to global capInitial and extended authorizations count toward the 182-day rolling 12-month maximum

Billing Codes & Limits

Billing code and modifierHCPCSCovered

H0043	Short-term post-hospitalization housing (Room & Board)
U3	Modifier specified for STPHH

inv-04: Service maximum limit — 182 calendar days (6 months) per rolling 12 months

Maximum duration182 calendar days (6 months) per rolling 12 months

Counting rulesCounts combined days of STPHH, Recuperative Care, and Transitional Rent toward the global cap

Non-reimbursementClaims will not be reimbursed if member has exhausted the 182-day limit

Authorization, Documentation & Provider Responsibilities

Prior Authorization

Prior Authorization Required

STPHH has a seven-day presumptive authorization period, contingent upon the Plan's approval of eligibility, submission of required documentation, and confirmation that the member has not reached the six-month global cap. If the presumptive authorization is denied, that period is ineligible for reimbursement; the member does not assume financial responsibility.

Seven-day presumptive authorization — contingent on eligibility, required documentation, and remaining global cap days.
If presumptive authorization is denied, the seven-day period is not reimbursable.

Billing Rule

Authorization Timing, Duration & Cap

Initial authorization may be approved for up to 90 days based on individual needs. STPHH cannot exceed a total duration of six months (182 calendar days) per rolling 12-month period across Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent (the global cap). Providers must confirm prior authorizations and remaining days in the provider portal before submitting requests; claims for members who have exhausted the 182-day limit or who do not meet eligibility will not be reimbursed.

Initial authorization: up to 90 days.
Service maximum: 182 calendar days (6 months) per rolling 12 months across related room & board services.
Providers must verify remaining days and prior authorizations in the provider portal before submission.

Documentation Required

Required Documentation for Initial Authorization

A Short-Term Post-Hospitalization Housing Referral Form and supporting documentation are required for initial authorization and extension requests. For individuals recovering from physical illness or injury include: history and physical, and discharge summary from the recovery program. For individuals recovering from a behavioral health condition include: history and physical (detailing diagnoses, high-risk diagnoses, medications, comorbidities, substance use issues, and psychosocial risk factors) and discharge summary from the recovery program.

Required form: Short-Term Post-Hospitalization Housing Referral Form.
Physical recovery: attach history & physical and discharge summary.
Behavioral health recovery: attach detailed history & physical and discharge summary.

Documentation Required

Reauthorization Documentation

For reauthorization/extension requests, submit a reassessment of the member's needs completed by a licensed professional along with the authorization request. Extensions may be approved based on individual needs, up to the remaining days available under the six-month service limit. Providers must document continuing need and clinical rationale in the reassessment.

Reassessment by a licensed professional required for each reauthorization request.
Extensions approved only up to remaining days under the 182-day rolling 12-month cap.
Include clinical rationale and documentation of continued need in the reassessment.

Denial Risk

Denial & Reimbursement Risk

If an authorization request is denied, any presumptive authorization period is not payable. Providers accepting members who do not meet eligibility or have exhausted the service maximum will not be reimbursed. Confirm member eligibility and remaining service days prior to acceptance to avoid denial and nonpayment risk.

Denied authorizations: presumptive days are ineligible for reimbursement.
Providers are responsible for confirming eligibility and remaining cap days before accepting placement.

Step Therapy

There is no specified step therapy requirement for STPHH in this policy. Providers should follow the documented authorization and documentation requirements when requesting services.

No step therapy specified for STPHH.

Note

Provider Responsibilities

Providers must have experience providing housing-related services in a culturally and linguistically appropriate manner and must use best practices. Confirm prior authorizations and remaining days in the provider portal before submitting authorization requests. Failure to confirm eligibility or service availability may result in denied claims and nonpayment.

Providers must verify prior authorizations and remaining service days in the provider portal before submission.
Providers should ensure culturally and linguistically appropriate services and adherence to best practices.

Key Definitions

inv-12: Short-Term Post-Hospitalization Housing (STPHH) definition

DefinitionInterim private or shared housing with supports for recuperation and recovery immediately after discharge from an inpatient or residential facility

PurposeProvides a safe, supportive environment to continue recovery from medical, psychiatric, or substance use treatment

Required supportsMay include assistance with ADLs, medical/behavioral care, case management, and linkage to housing supports

inv-13: Presumptive authorization definition — 7-day period pending approval

DefinitionA 7-day authorization period that allows service initiation pending the Plan's approval, submission of required documentation, and confirmation that the member has not reached the six-month global cap

Start conditionsService may begin immediately during this period while the Plan reviews eligibility and documentation

Denial consequenceIf the Plan denies authorization, the presumptive authorization period is ineligible for reimbursement

inv-14: Six-month global cap / Room & Board services definition

Global cap definitionCombined limit of six months (182 days) for Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent per rolling 12-month period

Service labelThese services are collectively referred to as 'Room & Board' services under waiver guidance

Operational noteProviders must verify member's prior authorizations and remaining days; exceeding the cap results in non-reimbursement

Background & Purpose

Short-Term Post-Hospitalization Housing (STPHH) provides a safe, supportive environment immediately after discharge to help members continue recovery from medical, psychiatric, or substance use treatment. The service is intended to support recuperation and recovery by offering assistance with activities of daily living, necessary medical/behavioral care, case management, and linkage to longer-term housing supports.

STPHH is designed for individuals leaving an institutional stay who have ongoing physical or behavioral health needs that would otherwise require continued institutional care. Eligible settings include interim private or shared housing where members receive the described supports, and providers must have appropriate experience and use best practices in housing-related services.