CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health Agency Services

Defines coverage, billing, and documentation requirements for home health and home care services (skilled and non-skilled) provided by Home Health Agencies to Neighborhood Health Plan of Rhode Island members in Rhode Island, including limits for homemaker/personal care and EVV requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency Services (coverage criteria)

Policy CodePolicy N/A

Change TypeRevised (coding, definitions, EVV alignment)

Effective DateN/A

Next Review DateN/A

Key ActionVerify medical necessity and obtain a physician's order for skilled services before submitting authorization and claims.

SourceLink

POLICY UPDATE CHANGES

Updated policy to define personal care and homemaker services and RI holiday for TV modifier.

Updated policy name from Home Health Services Payment Policy to Home Health Agency Services Payment Policy and consolidated HHA coding to align with EVV requirements.

S5125, T1001Representative codes listed

Up to 6 hrs/wkHomemaker/personal care limits

EVV requiredEVV status

Record retention req'dDocumentation

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 and Eligibility Criteria

General coverage

Covered when ALL of the following are met:

Coverage preconditions: Services are provided under a written home care plan authorized by a health care professional and are within the scope of state licensure; services must be medically necessary.

References to EVV and state licensure; Neighborhood may use NCD/LCD/InterQual/EOHHS/CMS guidance to determine medical necessity.

Homemaking and Personal Care Coverage

Non-skilled homemaker and personal care are covered under these limits when NOT eligible for LTSS:

Homemaker/personal care limits: Homemaking and personal care services are covered for up to 6 hours per week for individuals or 10 hours per week for couples who do not meet Long Term Services and Supports (LTSS) eligibility criteria.6 hrs/week individual; 10 hrs/week couple

If a Medicaid-only adult member needs non-skilled services long-term, refer to EOHHS/DHS for LTSS waiver prior to requesting additional authorization; non-skilled services do not require a physician's order per state guidance.

Skilled Services

Skilled services covered when ALL of the following are met:

Skilled service requirements: A physician's order is required for skilled services for all lines of business; services must be within the scope of state licensure and performed by appropriately licensed clinicians (RN, LPN, PT, OT, SLP, masters-level social worker, etc.) as designated by the plan of care.

Services include skilled nursing (wound care, tube feedings, medication administration, ostomy care, aspiration care), skilled therapy (PT/OT/SLP) and rehabilitation nursing; documentation must support medical necessity per Neighborhood and CMS standards.

Excluded services under the Home Care Services benefit include items that would not be covered if furnished as inpatient services, prosthetic devices, services covered under the End-Stage Renal Disease program, medical social services provided to family members, dietary and nutritional personnel when not incidental to the plan of care, and respiratory care services. Additionally, drugs and biologicals are not covered in this benefit. These exclusions apply across all lines of business unless otherwise specified in the member’s contract or program requirements.

The policy also excludes certain programmatic or service configurations from coverage: combination services are not covered for the Commercial line of business, and homemaker services are non-covered for Commercial members. Respite and relief care are specifically non-covered for adult members age 22 and older.

For non-skilled supports, the policy limits coverage and disallows certain services depending on line of business. Homemaker services are only covered when the member also needs personal care services for non-LTSS members, and when covered are limited to up to 6 hours per week for individuals or 10 hours per week for couples. If a Medicaid-only adult member requires non-skilled services on a long-term basis, the member should be referred to the Department of Human Services to apply for a LTSS waiver before requesting authorization for additional hours.

For the Commercial line of business, homemaker services are non-covered, personal care is only covered when required within a skilled plan of care, and combination services are non-covered. Respite and relief care are not covered for adults age 22 and older.

Billing Codes, Modifiers, and Billing Rules

Home health HCPCS codes (selected)HCPCSCovered

S5125	Attendant care services; per 15 minutes
S5125-U1	Combination of personal care and homemaking, rendered at the same time, per 15 minutes (U1 modifier required)
S5125-U9	High Attendant care services; per 15 minutes Acuity
S5130	Homemaker service, NOS; per 15 minutes
S9097	Home visit for wound care
S9127	Social work visit, in the home, per diem

Skilled services HCPCS/CPT-like codesHCPCSCovered

S9128	Speech therapy in the home, per diem
S9129	Occupational therapy in the home, per diem
S9131	Physical therapy; in the home, per diem
T1001	Nursing assessment/evaluation
T1002	RN services, up to 15 minutes
T1003	LPN/LVN services, up to 15 minutes
T1030	Nursing care, in the home, by registered nurse, per diem
T1031	Care in the home by licensed practical nurse, per diem
G0151	Services performed by a qualified physical therapist in the home health or hospice

Therapy and aide servicesHCPCSCovered

G0152	Services by a qualified occupational therapist in the home health or hospice, per 15 minutes
G0153	Services by a qualified speech-language pathologist in the home health or hospice, per 15 minutes
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes

Date span billing rules and fractional units

Date span max per claim lineDates of service are limited to one week (7 days) per claim line; dates must be within the same month and consecutive within the span

When date-span billing is prohibitedDate span billing is prohibited for skilled services and for combination services when used with shift-differential modifiers unless the same modifier applies to each date of service in the span

Breaks and multiple shiftsA break in service within a date span requires a new claim line; multiple shifts on the same date may be billed on the same claim line with a cumulative total of hours for that date

Fractional units and incremental codesHourly codes submitted with fractional units (e.g., 1.5, 2.5) will be denied; use incremental (time‑based) codes when time does not meet hourly rounding requirements

Time-of-service billing ruleTime‑based codes must be billed for the actual date of service on which the time was rendered, not the scheduled shift start date

Provider Responsibilities and Documentation Requirements

Prior Authorization

Medical necessity and physician order requirement — all services must be medically necessary; verify eligibility, coverage, and authorizations

All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity. It is the provider's responsibility to verify member eligibility, coverage, and any required authorizations prior to rendering services. For questions, contact Provider Services at 1-800-963-1001.

Verify eligibility, coverage, and prior authorization requirements before providing services.

Documentation Required

PROVIDER ACTIONS — provider responsibilities

Physician's order is required for skilled services for all lines of business. Providers must ensure services that are excluded from the Home Care Services Benefit (for example: services that would not be covered if furnished as inpatient services, prosthetic devices, services covered under the End-Stage Renal Disease program, medical social services provided to family members, and non-incidental dietary/nutritional personnel) are not billed under this benefit. Homemaking services are covered only when the member also needs personal care services and are limited to up to 6 hours per week for individuals (10 hours for couples) who do not meet Long Term Services and Supports (LTSS) eligibility; refer Medicaid-only adult members needing long-term non-skilled services to DHS for LTSS waiver evaluation prior to authorization requests. Respite and relief care are non-covered for adult members age 22 and older.

Definitions and Modifier Guidance

Home Health / Home Care Services (definition and scope)

DefinitionHome Health / Home Care Services are services provided under a home care plan authorized by a physician or non‑physician practitioner (NPP)

Scope of skilled servicesSkilled services include care by licensed clinicians (RN, LPN, PT, OT, SLP, rehabilitation nursing) such as medication administration, clinical assessment, wound care, tube feedings, ostomy care, tracheostomy care

Scope of non‑skilled servicesNon‑skilled services include home health aide/CNA or homemaker tasks: personal care, assistance with ADLs, meal preparation, housekeeping, medication assistance (self‑administered, nonclinical)

Plan of care and licensureServices must be provided under a written home care plan authorized by a physician or NPP and be within the scope of state licensure

Combination service modifiers (U1, U9) and shift differentials

Background

Home Health Agencies provide skilled nursing and therapeutic services to members in their place of residence under a written home care plan authorized by a physician or nurse practitioner. Services may be delivered full-time, part-time, or intermittently and can include skilled nursing, skilled therapy (PT/OT/SLP), rehabilitation nursing, as well as non-skilled supports such as personal care and homemaking when included in the plan of care and permitted by coverage rules. Providers must deliver services within the scope of state licensure and the individualized plan of care, and skilled services require a physician’s order for all lines of business.