CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health Agency (HHA) Services — Coverage Criteria

Defines coverage, billing, documentation, EVV, and medical necessity criteria for home health, private duty nursing, skilled and non-skilled home care services for Neighborhood Health Plan of Rhode Island members across applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency (HHA) Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised (coding, PDN criteria, modifiers)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PDN prior authorization every 13 weeks with physician-signed plan of care and recent nursing notes.

SourceLink

POLICY UPDATE CHANGES

Updated for therapy services effective 10/1/24 grid coding.

Updated policy with clearer definitions for private duty nursing, non-skilled services, limitations and exclusions.

Defined personal care and homemaker services and RI holiday for TV modifier.

Updated policy name to Home Health Agency Services Payment Policy and aligned with EVV requirements.

13wPDN prior authorization renewal interval

6 hrs/wkMax homemaking/personal care (individual)

10 hrs/wkMax homemaking/personal care (couple)

Implemented Jan 2023

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MultipleCoding grid available

Coverage and Medical Necessity Criteria

General coverage and PDN criteria

Covered when ALL of the following are met:

Basic medical necessity and order: Services are ordered by a licensed physician (MD, DO, NP, PA) and provided under a written plan of care

physician order required for skilled services

Scope and provider qualifications: Services are performed within the scope of state licensure by appropriately licensed professionals as designated by the plan of care

coverage provided within scope of state licensure; private nursing and non-skilled services may be delivered by an HHA that is not Medicare‑certified

Setting: Services are provided in the member's home (non‑institutional) as defined by policy and are not covered when the member is a resident of a nursing hospital or licensed residential care facility

institutional settings are excluded

PDN-specific

PDN criterion 1: Ordered by a licensed physician as part of a treatment plan
physician‑signed plan of care required for authorization
PDN criterion 2: Member can be safely maintained in the home in the absence of nursing care
caregiver must be able to care for the member when nursing is not present
PDN criterion 3: Member's condition requires continuous skilled care greater than two (2) hours per day that can only be provided by an RN or LPN according to practice standards> 2 hours/day
InterQual assessment defines clinically appropriate PDN hour range
PDN criterion 4:

Duplication and overlap: Services must not duplicate other paid services (for example, PDN and home infusion nursing oversight); when duplication exists, the lowest level of care needed to safely meet the member's needs may be covered

Neighborhood may limit overlapping services

Homebound status: Beneficiaries are not required to be homebound for coverage

homebound status is not a coverage requirement

Homemaker and Personal Care limits

Covered when ALL of the following are met:

Homemaker-personal care linkage: Homemaking services are covered only when the member also needs personal care services

homemaking services are contingent on personal care need

Weekly hour limits for non-LTSS: For members who do not meet LTSS eligibility, homemaking and personal care services are limited to a weekly maximum<= 6 hrs/week for individuals; <= 10 hrs/week for couples

Members identified as high risk or whose CFNA indicates LTSS needs should be referred to EOHHS for LTSS waiver; service needs in CFNA may be covered for up to 90 days

LTSS referral and duration: Members who meet criteria for long‑term services and supports (LTSS) should be referred to EOHHS to apply for an LTSS waiver

CFNA‑identified LTSS needs may be covered by Neighborhood for up to 90 days pending referral

The policy excludes certain items and services from the Home Care Services benefit. Not covered are Drugs and biologicals, prosthetic devices, services that would not be covered if furnished as inpatient services, and services covered under the End-Stage Renal Disease (ESRD) program. Also excluded are medical social services provided to family members, respiratory care services, and dietary/nutritional personnel when not incidental to the care plan. For Commercial lines, homemaker services and combination services are non-covered, and personal care is only covered if required within a skilled plan of care. The cost of home health services must not exceed the cost of equivalent institutional care.

Home Health services are not covered when the member is a resident of a nursing hospital or a licensed residential care facility. Providers should not bill Neighborhood for home health services provided to members residing in these institutional settings. Additionally, services provided solely to allow a caregiver to work or attend school are not covered; lack of an available caregiver does not convert an otherwise non‑skilled need into a skilled service. For Commercial members, homemaker services are specifically non‑covered.

The policy identifies that services which duplicate or overlap may be limited. Examples include concurrent Private Duty Nursing (PDN) and home infusion nursing oversightlowest level of care needed to safely meet the member’s needs. Providers should avoid billing multiple programs for the same need and should select the appropriate, lowest‑cost service that meets clinical requirements.

Service Codes, Modifiers, and Coding Rules

Covered HCPCS S-codesHCPCSCovered

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 must be included each time this service is billed.
S5125-U9	High Acuity Attendant care services; per 15 minutes.
S5130	Homemaker service, NOS; per 15 minutes.
S9097	Home visit for wound care.
S9127	Social work visit, in the home, per diem.

Covered HCPCS T-codesHCPCSCovered

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	Nursing care in the home by licensed practical nurse, per diem.

Covered Medicare G-codesHCPCSCovered

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice setting, each 15 minutes.

ModifiersModifier

TV	Weekend / Rhode Island State Holiday Shift modifier.
UH	Evening Shift 3PM-11PM modifier.
UJ	Night Shift 11PM-7AM modifier.

PDN continuous skilled care threshold

Threshold>2 hours per day indicates continuous skilled care

ContextApplies when skilled nursing care required continuously and can only be conducted by an RN or LPN per practice standards

Use in authorizationInterQual PDN Assessment used to determine clinically appropriate PDN hours and medical necessity reviews

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

PDN Prior Authorization and Documentation Requirements

Prior authorizations are required for Private Duty Nursing (PDN) and must be renewed every 13 weeks. Neighborhood uses the InterQual PDN Assessment to determine medical necessity and an appropriate range of PDN clinical hours. To facilitate review, submit a physician-signed plan of care and the most recent 2 weeks of nursing notes with authorization requests.

PDN prior auth renewals: every 13 weeks
InterQual PDN Assessment used to determine clinical hours range and medical necessity
Submit physician-signed plan of care and most recent 2 weeks of nursing notes with auth requests

Billing Rule

Coding, Modifiers, and EVV Considerations

Key Definitions

'Home' definition

DefinitionAny place the member has established residence while receiving services

Excluded locationsHospitals, skilled nursing facilities (SNFs), intermediate care facilities, and other institutional facilities are not considered 'home'

Setting requirementServices must be provided in the member's home (non-institutional) as defined by policy

Private Duty Nursing (PDN) definition

DefinitionIndividual and continuous skilled nursing provided by licensed nurses, delivered on a per-hour or per-block-hours basis (not intermittent or unique visits)

Intended populationMembers with complex medical conditions or disabilities managed at home; supportive to caregiver efforts and not intended to replicate nursing home services

Background

Home Health Agencies provide skilled nursing, therapy, and supportive non‑skilled services in the member’s residence under the direction of a physician or authorized non‑physician practitioner and a written plan of care. Private Duty Nursing (PDN) is individualized, continuous skilled nursing for members with complex medical needs and is intended to support keeping the member safely at home; PDN is not a substitute for institutional care and requires a physician order and a physician‑approved treatment plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency (HHA) Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised (coding, PDN criteria, modifiers)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit PDN prior authorization every 13 weeks with physician-signed plan of care and recent nursing notes.

SourceLink

On This Page

There is a physician‑approved written treatment plan with short‑ and long‑term specified goals

submit treatment plan and most recent 2 weeks of nursing notes with authorization requests

PDN criterion 5: Member's skilled care needs exceed what can be provided by a Certified Nursing Assistant (CNA)

services must be reasonable and necessary and within licensed nurse scope

Non-skilled services order requirement: Non‑skilled homemaking and personal care services do not require a physician's order

physician order is required only for skilled services

Billing and coding must reflect the line of business and service acuity. Some services require specific modifiers and are subject to EVV reporting. Include required modifiers at claim submission (for combination services the shift differential modifier must precede the acuity modifier). Ensure EVV compliance for applicable codes and lines of business.

S5125-U1: U1 modifier required each time this combination personal care/homemaking service is billed
Use acuity modifiers (e.g., U9) where applicable; when both shift differential and acuity modifiers apply, the shift differential modifier must precede the acuity modifier
EVV applicability: codes marked with EVV Phase 1 or 2 require EVV reporting per program guidance
Verify line-of-business-specific billing rules (Medicaid, Integrity, All) before claim submission

Documentation Required

Medical Record and Documentation Requests

Neighborhood may request medical records for any billed service. Documentation must support billed services and medical necessity; failure to provide adequate documentation may result in denial or recovery of payments. Maintain records in accordance with Rhode Island and federal regulations.

Medical record must include: patient identification, source of referral, physician name and contact, signed plan of care, objectives, diagnoses, nursing assessments, signed dated clinical and progress notes, documentation of plan of care reviews and physician summaries, and discharge summaries
For PDN authorizations, Neighborhood may request additional documentation such as a physician-signed plan of care and the most recent 2 weeks of nursing notes
Neighborhood follows CMS standards for documentation and may deny or recover payments if records do not support billed services

Denial Risk

Denial Risk for Lack of Medical Necessity or Institutional Residence

Services provided to members who are residents of a nursing facility or licensed residential care facility are not covered under Home Health Services. Providing services that are not medically necessary or that lack required documentation risks denial and recoupment of payments.

Home health services are not covered for institutional residents (nursing hospital or licensed residential care facility)
Neighborhood may deny or recover payments if documentation does not support medical necessity or billed services

Coverage prerequisitesRequires physician-ordered treatment plan with short- and long-term goals and that the member can be safely maintained in the home in absence of nursing care

Scope and limitsServices must be reasonable and necessary, within licensed nursing scope, exceed CNA capabilities, and meet InterQual PDN Assessment medical necessity