ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health Agency Services Payment Policy

Defines coverage, medical necessity prerequisites, EVV requirements, covered and excluded home health/home care services, billing and documentation rules, and line-of-business specific limitations for Neighborhood Health Plan of Rhode Island (Medicaid, INTEGRITY, Commercial).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency Services Payment Policy

Policy CodePolicy N/A

Change TypeModified — multiple updates including benefit limits, coding grid, and definitions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit physician-signed plan of care and the most recent 2 weeks of nursing notes; prior authorizations must be renewed every 13 weeks.

SourceLink

POLICY UPDATE CHANGES

6/30/25: Updated Benefit limitations and exclusions to separate out Medicaid and INTEGRITY with EOHHS guidance.

12/20/24: Updated coding grid for therapy services effective 10/1/24.

09/18/24: Policy review and updated definitions for private duty nursing, non-skilled services and limitations and exclusions.

07/01/24: Updated policy to define personal care and homemaker services and RI holiday for TV modifier.

01/01/24: Updated policy name and consolidated HHA coding to align with EVV requirements.

09/29/21: Policy review date with no content changes.

3Lines of business (Medicaid, INTEGRITY, Commercial)

13Key HCPCS/T codes listed

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6Required documentation elements (enumerated)

13wPrior authorization renewal interval (PDN)

Policy overview

Payer: Neighborhood Health Plan of Rhode Island. Policy Title: Home Health Agency (HHA) Services Payment Policy. Effective/Review dates header: Last review 2025-06-30; see Document History for prior revisions (notably 06/30/25, 12/20/24, 09/18/24, 07/01/24, 01/01/24).

Purpose: Defines payment, coverage, and medical necessity requirements for home health and home care services provided by Home Health Agencies in Rhode Island, including skilled and non-skilled services, private duty nursing (PDN), homemaker/personal care, and therapy services. The policy aligns with federal/state EVV implementation and EOHHS guidance and references InterQual PDN assessment and applicable NCDs/LCDs for medical necessity determinations.

Scope: This policy applies to lines of business: Medicaid (excluding EFP), INTEGRITY, and Commercial. It governs services delivered under a physician- or NPP-authorized home care plan in the member's home setting by HHAs and requires adherence to Rhode Island licensure and EOHHS/EVV requirements.

Skilled vs Non-Skilled distinction: Skilled services (e.g., nursing assessments, RN/LPN visits, therapy codes) must be delivered per scope of licensure and require a physician order for skilled services across all lines. Non-skilled services include personal care, homemaking, and home health aide services (including attendant care codes) and have separate coverage rules (e.g., homemaking often requires coexisting personal care for Medicaid/INTEGRITY).

EVV alignment: Per federal SSA requirements and EOHHS implementation, providers must use an EVV system for Medicaid-funded PCS and HHCS by January 2023; specific codes are designated for EVV Phase I or II in the coding grid and must follow EVV rules.

Who this applies to: Home Health Agencies operating in Rhode Island that provide skilled nursing, therapy, PDN, and non-skilled homemaker/personal care services and who bill Neighborhood for reimbursement.

Medical necessity and coverage criteria

General Medical Necessity

Services must be medically necessary and meet the following:

ALL of the following

Services are medically necessary
Services are provided under a written home care plan authorized by a physician or non-physician practitioner (NPP)
Services are performed within the scope of state licensure as defined by the Rhode Island Department of Health
Services are delivered in a home setting (member's residence, friend's/family home, group home, homeless shelter or other temporary residence). Institutional facilities and adult day care do not qualify as home setting

Code lists and modifiers (EVV phases noted)

Non-skilled/home care attendant and homemaker codes (EVV Phase 1 or 2, Non-skilled)HCPCSCovered

S5125	Attendant care services; per 15 minutes. EVV Phase 1 or 2 = 1. Non-Skilled. Line of Business = All.
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. EVV Phase 1 or 2 = 1. Non-Skilled. Line of Business = Medicaid & INTEGRITY.
S5125-U9	High Acuity Attendant care services; per 15 minutes. EVV Phase 1 or 2 = 1. Non-Skilled. Line of Business = All.
S5130	Homemaker service, NOS; per 15 minutes. EVV Phase 1 or 2 = 1. Non-Skilled. Line of Business = Medicaid & INTEGRITY.

Skilled home health and therapy codes (EVV Phase 2, Skilled)mixedCovered

S9097	Home visit for wound care. EVV Phase = N/A. Skilled. Line of Business = All.
S9127	Social work visit, in the home, per diem. EVV Phase = 2. Skilled. Line of Business = All.
T1001	Nursing assessment/evaluation. EVV Phase = N/A. Skilled. Line of Business = All.
T1002	RN services, up to 15 minutes. EVV Phase = 2. Skilled - PDN Only. Line of Business = All.
T1003	LPN/LVN services, up to 15 minutes. EVV Phase = 2. Skilled - PDN Only. Line of Business = All.
T1030	Nursing care, in the home, by registered nurse, per diem. EVV Phase = 2. Skilled. Line of Business = All.
T1031	Nursing care, in the home, by licensed practical nurse, per diem. EVV Phase = 2. Skilled. Line of Business = All.
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. EVV Phase = 2. Skilled. Line of Business = All.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. EVV Phase = 2. Skilled. Line of Business = All.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. EVV Phase = 2. Skilled. Line of Business = All.

1–10 of 11

1/2

Modifiers applicable to combination/shift/acuity servicesModifier

U1	Combination of personal care and homemaking modifier (required each time billed for S5125-U1).
U9	High Acuity modifier for S5125 when applicable.
TV	Weekend/Rhode Island State Holiday Shift (shift differential). Must precede acuity modifier when both applicable.
UH	Evening Shift 3PM-11PM (shift differential).
UJ	Night Shift 11PM-7AM (shift differential).

Actionable billing, documentation & EVV requirements

Prior Authorization

Prior Authorization required for PDN and recurring services

Submit physician-signed plan of care and the most recent 2 weeks of nursing notes with prior authorization requests. Prior authorizations are required every 13 weeks. Affected codes: T1002, T1003, T1030, T1031, S5125, S5130.

Affected codes: T1002, T1003, T1030, T1031, S5125, S5130
Must submit physician-signed plan of care
Include most recent 2 weeks of nursing notes with PA request
Prior authorization renewal every 13 weeks

Billing Rule

EVV requirement

Providers must use an Electronic Visit Verification (EVV) system for Medicaid-funded personal care services (PCS) and home health care services (HHCS) by January 2023. EVV applies to the codes and phases noted in the coding grid; affected codes include S5125, S5125-U1, S5125-U9, S5130, G0156, T1002, T1003, T1030, T1031, and S9127 (see coding grid for EVV phase assignments).

Key definitions

Definitions

Home settingMember's residence including dwelling, apartment, home of friend/family, group home, homeless shelter or temporary residency; excludes hospitals, skilled nursing facilities, intermediate care facilities, other institutional facilities, and adult day care.

Private Duty Nursing (PDN)Individual, continuous skilled one-on-one care provided by licensed nurses, billed per hour or per block hours, intended for complex medical conditions managed at home; not intended to replicate nursing home services.

Combination service (U1)Combination of personal care and homemaking rendered at the same time; U1 modifier is required each time this service is billed.

EVV PhaseElectronic Visit Verification phase (1 or 2) indicating applicability for certain codes per Rhode Island/EOHHS implementation.

Quantitative limits and thresholds

Thresholds / Limits

PDN continuous skilled care threshold> 2 hours per day (member's condition requires continuous skilled care greater than two (2) hours per day that can only be conducted by an RN or LPN)

Prior Authorization Renewal IntervalEvery 13 weeks (Prior Authorizations are required every 13 weeks)

Homemaking/Personal Care weekly limits (Medicaid & INTEGRITY)Individuals up to 6 hrs/week; couples up to 10 hrs/week (Homemaking and Personal Care services are covered for up to 6 hrs per week for individuals or 10 hrs per week for couples who do not meet LTSS eligibility)

Medicaid and INTEGRITY weekly limits and coverage maximums: Homemaking and Personal Care are covered up to 6 hrs/week for individuals or 10 hrs/week for couples who do not meet LTSS eligibility; homemaking is only covered when the member also needs personal care (Medicaid). INTEGRITY similarly covers homemaking and personal care up to the same weekly limits and will cover CFNA-identified needs for up to 90 days; nonskilled services for INTEGRITY do not require a physician's order.

Medicaid exclusions and limits: Respite and Relief Care are non-covered for adult members (22 and older). If a Medicaid adult needs long-term non-skilled services, referral to DHS for LTSS waiver is required before authorizing ongoing hours.

Policy changes & timeline

06/30/25revisedLatest

Updated Benefit limitations and exclusions to separate out Medicaid and INTEGRITY with EOHHS guidance.

12/20/24revised

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

09/18/24revised

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency Services Payment Policy

Policy CodePolicy N/A

Change TypeModified — multiple updates including benefit limits, coding grid, and definitions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit physician-signed plan of care and the most recent 2 weeks of nursing notes; prior authorizations must be renewed every 13 weeks.

SourceLink

On This Page

Private Duty Nursing (PDN) Medical Necessity

PDN may be considered medically necessary when ALL of the following are met:

ALL of the following

Services are ordered by a licensed physician (MD, DO, NP, PA) as part of a treatment plan
The member can be safely maintained in the home in the absence of nursing care
The member's condition requires continuous skilled care greater than two (2) hours per day that can only be conducted by an RN or LPN according to practice standards> 2 hours per day
continuous skilled care
The member's needs for skilled care are greater than what can be provided by a Certified Nursing Assistant (CNA)
There is a physician approved written treatment plan with short and long-term goals specified
Services provided are reasonable and necessary and within the scope of practice of a licensed nurse
Medical necessity criteria must be met within the InterQual Private Duty Nursing (PDN) Assessment

Prior Authorization for PDN

Operational requirements for PDN prior authorization:

ALL of the following

Submit physician-signed plan of care and most recent 2 weeks of nursing notes with prior authorization requests
Prior Authorizations are required every 13 weeksEvery 13 weeks
renewal interval

Line of Business Specific Coverage Constraints

Coverage differs by line of business:

Line-specific rules (select applicable)

Medicaid & INTEGRITY (shared rules)
- Homemaking and Personal Care services are covered for up to 6 hrs/week for individuals or 10 hrs/week for couples who do not meet LTSS eligibilityIndividuals up to 6 hrs/week; couples up to 10 hrs/week
  Medicaid & INTEGRITY limit
- Homemaking services are only covered when the member also needs personal care services (Medicaid)
  Medicaid condition
- Respite and Relief Care are non-covered for adult members (22 and older) (Medicaid)
  Medicaid exclusion
- Home care services with codes T1000, T1001, S5125, S5130 and associated modifiers must be delivered and billed as one-on-one care only (Medicaid & INTEGRITY)
  one-on-one requirement
- Providers must follow EOHHS staff assignment and conflict-of-interest limitations (no assignment to residents, family relationships, guardianship/POA/authorized rep)
  EOHHS staffing limitations
- INTEGRITY: Services must be provided by a Medicare-certified home health agency; nonskilled services do not require a physician's order; service needs identified in CFNA covered up to 90 days90 days
  INTEGRITY provisions
Commercial
- Personal care is only covered if required within a skilled plan of care (Commercial)
  Commercial condition
- Homemaker services are non-covered (Commercial)
  Commercial exclusion
- Combination services are non-covered (Commercial)
  Commercial exclusion
- Commercial plans include cost-sharing (coinsurance, copays, deductibles) per member plan
  Member responsibility applies

Duplication / Overlap

ALL of the following

Home Health services are not covered if the member is a resident of a nursing facility, hospital, or licensed residential care facility
exclusion
Home Health services are not covered solely to allow caregiver to work or attend school
exclusion
It is duplication or overlap for a member to receive Private duty nursing services and home health aide services, and/or PDN services and home infusion nursing oversight services; when duplication exists, the lowest level of care needed to safely meet the member's needs may be covered
duplication rule

Affected codes: S5125, S5125-U1, S5125-U9, S5130, G0156, T1002, T1003, T1030, T1031, S9127
EVV required for Medicaid-funded PCS and HHCS by Jan 2023
See coding table for EVV Phase assignments (Phase 1 = PCS, Phase 2 = HHCS)

Billing Rule

Date span billing rules for non-skilled services

Date span billing is permitted for non-skilled services only when dates of service are limited to one week (7 days) per claim line, services were provided consecutively on each date within the span, any break requires a new claim line, and dates of service must be within the same month.

One-week (7 days) per claim line limitation
Dates must be consecutive within the span
Any break in service requires a new claim line
Dates of service must be within the same month

Billing Rule

Prohibition of date span billing for skilled services

Date span billing is prohibited for skilled services. Combination services are also excluded from date span billing when using shift differential modifiers unless the modifier applies to each date of service in the span.

Date span billing prohibited for skilled services
Combination services with shift differential modifiers cannot use date spans unless modifier applies to every date

Billing Rule

Time reporting and incremental codes

Use incremental codes for fractional hourly time; hourly codes submitted with fractional units (e.g., 1.5, 2.5) will be denied. Time-based codes must be billed for the date the service was rendered, not the scheduled shift start date.

Fractional hourly units billed with hourly codes will be denied
Use incremental codes for time not meeting hourly rounding
Bill time-based codes for the date rendered

Documentation Required

Documentation requirements for reimbursement

Maintain a medical record for each member that includes patient identification, source of patient referral, physician name, plan of care, personal care and homemaker objectives (where applicable), medical diagnosis and nursing assessment, orders (drug, dietary, treatment, activity), signed and dated clinical/progress notes, signed and dated records of service refusals, copies of summary reports to the attending physician, changes/reviews of the plan of care signed by the responsible professional, documentation of advance directives (if any), and discharge summaries. Records must be kept in accordance with Rhode Island and federal regulations.

Patient identification (name, address, birth date, gender, admission/readmission date)
Source of patient referral
Name of physician (address and phone)
Plan of care and objectives (personal care/homemaker where applicable)
Diagnosis, nursing assessment, goals, prognosis, relevant conditions
Orders (drug, dietary, treatment, activity)
Signed, dated clinical/progress notes and service refusals
Summary reports to physician and plan changes signed by responsible professional
Advance directive documentation and discharge summaries

Denial Risk

Denial for out-of-scope or non-home settings

Claims may be denied if services are provided outside a home setting (for example: hospital, skilled nursing facility, or other institutional facility) or if services are billed as skilled when the clinical criteria for skilled care are not met.

Services must be performed within a defined home setting to be payable
Claims billed as skilled may be denied if skilled criteria (e.g., physician order, scope of practice) are not met

Documentation Required

Medical records subject to audit

Neighborhood may request medical records for any billed service; all services are subject to audit. Documentation must support the services billed and the medical necessity of those services and meet CMS, Rhode Island state, and federal standards.

Neighborhood may request records for any service billed
Documentation must support billed service and medical necessity
Records must meet CMS standards and state/federal regulations

One-on-one care / code-specific requirement: For Medicaid and INTEGRITY, services billed with procedure codes T1000, T1001, S5125, S5130 and associated modifiers must be delivered and billed as one-on-one care only. The coding grid specifies combination (U1) and high-acuity (U9) modifiers for attendant care codes (e.g., S5125-U1 for combination personal care/homemaking) and EVV phase applicability; shift differential modifiers (TV, UH, UJ) may also apply with ordering rules.

Commercial line distinctions: Personal care is only covered when required within a skilled plan of care; homemaker and combination services are non-covered for Commercial. Commercial members may have cost-sharing (coinsurance, copays, deductibles) per plan.

Billing notes tied to limits: Date span billing is allowed for non-skilled services but limited to one week (7 days) per claim line with consecutive dates, while date span billing is prohibited for skilled services and for combination services when using shift differential modifiers unless the modifier applies to each date in the span.

Policy review and updated definitions for private duty nursing, non-skilled services and limitations and exclusions.

07/01/24revised

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

01/01/24revised

Updated policy name and consolidated HHA coding to align with EVV requirements.

09/29/21revised

Policy review date with no content changes.