ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health / Home Care Services — Coverage Criteria

Defines coverage, authorization, billing, and documentation requirements for home health and home care services provided to Neighborhood Health Plan of Rhode Island members across Medicaid and commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health / Home Care Services — Coverage Criteria (coverage_criteria)

Policy CodePolicy N/A

Change TypeMaterial revisions to benefit limitations/exclusions and coding updates

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for Private Duty Nursing (PDN) every 13 weeks using the InterQual PDN Assessment.

SourceLink

POLICY UPDATE CHANGES

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

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

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

13 wksPDN authorization cadence

6 hrs/wkMedicaid wkly limit (individual)

10 hrs/wkMedicaid wkly limit (couples)

7 daysDate-span billing max

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Coverage and Medical Necessity Criteria

Private Nursing (PDN) — Medical Necessity

Private Nursing (PDN) services may be considered medically necessary when ALL of the following are met:

PDN criteria: 1) Services are ordered by a licensed physician (MD, DO, NP, PA) as part of a treatment plan; 2) The member can be safely maintained in the home in the absence of nursing care; 3) 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; 4) There is a physician-approved written treatment plan with short- and long-term specified goals; 5) The member's needs for skilled care are greater than what can be provided by a Certified Nursing Assistant (CNA); 6) Services are reasonable and necessary and within the scope of practice of a licensed nurse; 7) Medical necessity criteria are met within the InterQual Private Nursing (PDN) Assessment.

To facilitate reviews submit physician-signed plan of care and most recent 2 weeks of nursing notes; prior authorizations required every 13 weeks.

Skilled Services — Coverage Criteria

Covered skilled services — when ALL apply:

Skilled services: 1) Physician order is required for skilled services for all lines of business; 2) Services must be within the scope of state licensure and the member's plan of care; 3) Documentation must support medical necessity and the skilled nature of services.

Skilled therapy and nursing codes identified in coding section (e.g., G0152, G0153, T1001, T1002, T1003, T1030, T1031, 60151).

Non-Skilled Services (Medicaid)

Medicaid non-skilled coverage rules:

Non-skilled homemaking and personal care: 1) Homemaking services are only covered when the member also needs personal care services; 2) Homemaking and personal care are covered up to 6 hours per week for individuals or 10 hours per week for couples who do not meet LTSS eligibility; 3) Non-skilled services do not require a physician's order; 4) Service needs identified in the Comprehensive Functional Needs Assessment (CFNA) will be covered for up to 90 days while an LTSS referral is completed.

Respite and Relief Care non-covered for adult members age 22 and older.

Service classification — Coverage and classification statements

Coverage and classification as stated in the document

HCPCS service definitions: G0152 and G0153 are classified as Skilled services; G0156 is Non-Skilled when billed within a Skilled plan of care.

G0156 Line of Business specified as Medicaid & INTEGRITY; shift-differential modifiers (TV, UH, UJ) apply as defined in coding guidance.

Home health services are not covered when the member is a resident of a nursing hospital or a licensed residential care facility; institutional placement removes eligibility under the Home Care Services benefit. When duplication or overlap of services exists (for example, private nursing and home infusion nursing oversight), coverage may be limited to the lowest level of care needed to safely meet the member's needs. Additionally, services identified in a child's IEP as the responsibility of the school district (LEA/FAPE) are not covered by NHPRI.

The policy expressly excludes certain items and service categories from the Home Care Services benefit. Notable exclusions include: Drugs and biologicals, services covered under the End-Stage Renal Disease (ESRD) program, services that would not be covered if furnished as inpatient services, prosthetic devices, respiratory care services, medical social services provided to family members, and dietary/nutritional personnel when such services are not incidental to the authorized care plan.

The policy history documents operational changes that separate benefit limitations and exclusions by line of business: Medicaid and INTEGRITY were split per EOHHS guidance. The document history also notes prior updates affecting coding grids and definitions. Providers should note that exclusions and limitations may vary by line of business and review the Document History for effective dates and the specific language that applies to Medicaid, INTEGRITY, and commercial lines.

Home Health services are not covered solely to allow a caregiver to work or attend school; lack of an available caregiver does not convert an otherwise unskilled service into a skilled service. In other words, caregiver availability alone is not a medical justification to authorize skilled-level home health services.

This payment policy is informational and does not address every possible reimbursement scenario; it is not a guarantee of reimbursement. Claim payments remain subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. All billed services are subject to audit.

HCPCS/CPT Codes, Modifiers, and Billing Rules

Covered HCPCS/CPT-like codes listedmixedCovered

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.
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.

1–10 of 15

1/2

Applicable modifiersModifier

Modifiers: TV, UH, UJ

TV = Weekend/RI State Holiday Shift; UH = Evening Shift 3PM-11PM; UJ = Night Shift 11PM-7AM. Shift differential modifier must precede acuity modifier when both apply.

Home Health / Hospice HCPCS CodesHCPCSCovered

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 settings, each 15 minutes.

ModifiersModifier

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

Date-span billing limits

Maximum date-span lengthDates of service are limited to one week (7 days) per claim line.

Breaks in serviceA break in service within a date span must be billed on a new claim line (e.g., non-consecutive dates).

Same-month requirementDates of service on a date-span claim line must be within the same month.

Prohibited for skilled servicesDate-span billing is prohibited for skilled services and for combination services when shift differential modifier does not apply to each date in the span.

Incremental time reportingIncremental codes must be used when time does not meet hourly rounding requirements; hourly codes submitted with fractional units (1.5, 2.5, etc.) will be denied.

Authorization, Documentation, and Audit Requirements

Prior Authorization

Prior authorization may be required

Prior authorizations may be required for private duty nursing (PDN) and other home health services. Providers must verify prior authorization and member eligibility with Neighborhood Health Plan of Rhode Island before rendering services. Failure to obtain required prior authorization may result in denial or recoupment of payment.

Prior Authorizations for PDN are required every 13 weeks and decisions reference the InterQual PDN Assessment.
Confirm prior authorization and benefit coverage via Neighborhood's provider portal or Provider Services at 1-800-963-1001.

Denial Risk

Improper time reporting denial risk

Claims with fractional hourly units (e.g., 1.5, 2.5) submitted using hourly codes will be denied. Use incremental (time-based) codes when service time does not meet hourly rounding requirements. Bill time-based codes for the actual date of service on which the care was rendered.

Background and Policy Scope

Home health services are delivered in the member's residence to provide skilled nursing, therapy, and supportive non‑skilled services under a physician- or authorized provider-approved plan of care. The program includes skilled nursing and therapy (PT/OT/SLP), Private Duty Nursing (PDN) for continuous 1:1 nursing when medically necessary, and non-skilled personal care and homemaking when allowed by payer rules. Services are intended to allow safe care in the home, avoid unnecessary institutionalization, and must be documented to support medical necessity and scope of service.

Key Definitions and Code Descriptions

Home — definition

DefinitionAny place where the member has established residence at the time services are provided, including private dwellings, family/friend homes, group homes, shelters, or temporary residences.

Excludes institutional settingsInstitutional facilities (e.g., nursing hospitals, licensed residential care facilities) are not considered 'home' for home health coverage purposes.

Authorization contextHome Health/Home Care Services are those provided under a home care plan authorized by a physician or non-physician practitioner.

Private Duty Nursing (PDN) — definition & billing

DefinitionPrivate Duty Nursing (PDN) is individual, continuous skilled 1-on-1 nursing care provided by licensed nurses (RN/LPN) intended for members with complex medical conditions managed at home.

Billing units