ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health / Home Care Services - Coverage Criteria

Defines coverage, reimbursement, and documentation requirements for home health and home care services delivered by Home Health Agencies to Neighborhood Health Plan of Rhode Island members across applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health / Home Care Services - Coverage Criteria

Policy CodePolicy N/A

Change TypeDefinitions and coding updates (EVV, modifiers, PDN limits)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization every 13 weeks for Private Duty Nursing and submit physician-signed plan of care plus two weeks of recent nursing notes for PDN reviews.

SourceLink

POLICY UPDATE CHANGES

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

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

Consolidated HHA coding to align with EVV requirements.

Jan 2023EVV implementation

13 wksPDN auth frequency

6 hrs/wkHomemaking cap (individual)

10 hrs/wkHomemaking cap (couples)

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Coverage Criteria and Limits

Covered Services

Covered services include the following when provided under a physician/NPP-authorized plan of care and within scope of licensure:

Skilled Nursing: Services must be rendered by a licensed RN or LPN within scope of licensure as designated by the plan of care (examples: administration of medications; clinical patient assessment; tube feedings; catheter care; nasopharyngeal/tracheostomy aspiration and care; wound care; ostomy care).

Private Duty Nursing (PDN): Continuous individual skilled nursing care provided by licensed nurses billed per hour or block hours; intended for members with complex conditions managed at home; coverage requires a physician‑ordered written treatment plan with short‑ and long‑term goals, the member can be safely maintained in the home in the absence of nursing, needs exceed what a CNA can provide, and services are reasonable and within the scope of practice of a licensed nurse.Continuous skilled care > 2 hours/day

InterQual PDN Assessment used to determine clinically appropriate PDN hours; prior authorization required every 13 weeks; submit physician‑signed plan of care and most recent 2 weeks of nursing notes for medical necessity review.

Skilled Therapy: Occupational therapy (OT), physical therapy (PT), speech‑language pathology (SLP), and therapy assistants must render services per the plan of care and within scope of licensure to be covered.

Non‑Skilled Services: Home health aide/CNA/homemaker services for assistance with ADLs, medication assistance (self‑administered, non‑clinical), meal preparation, routine household tasks, and direct support for tasks the member cannot complete independently. Homemaking services are covered only when the member also needs personal care.Homemaking limited to 6 hrs/week for individuals and 10 hrs/week for couples not meeting LTSS eligibility

Non‑skilled services do not require a physician order except personal care when required within a skilled plan of care; long‑term non‑skilled needs should be referred to DHS for LTSS waiver consideration.

General Coding & Modifier Rules

Covered when billed with appropriate code and per plan and documentation requirements

Code‑level requirements: Services billed under codes T1031, G0151, G0153, and G0156 must be billed with the appropriate EVV phase and with the correct skilled vs non‑skilled designation as listed in the policy. Shift differential modifiers (TV, UH, UJ) may apply; the shift differential modifier must precede an acuity modifier when both are used.

Applies to all lines of business as indicated for each code (see coding module).

Billing unit rules: Hourly/block nursing codes and attendant care codes must be billed in the required units; fractional hourly units (e.g., 1.5, 2.5) for hourly codes will be denied—use incremental codes as specified. Date‑span billing is prohibited for skilled services and combination services with shift differential modifiers unless the modifier applies to all dates in the span.

Claims remain subject to member eligibility, benefit coverage, coding/documentation, authorization policies, provider contract, and state/federal regulations.

Services that are excluded from coverage under the Home Care Services benefit include 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 such services are not incidental to the home care plan. Homemaking services are only covered when the member also needs personal care services; additional limits and line-of-business rules apply.

For the Commercial line of business, homemaker services are non-covered and combination services are non-covered. Personal care is covered only when it is required within a skilled plan of care. Separately, for non-LTSS members, homemaking/personal care has weekly caps when covered with personal care (see coding/threshold sections): homemaking capped at 6 hours/week for individuals and 10 hours/week for couples when LTSS criteria are not met.

Respite and relief care are explicitly non-covered for adult members age 22 and older across lines of business.

The policy document history records that exclusion language specific to the Commercial line of business was added on 11/03/20. Subsequent updates clarified definitions and coverage distinctions for personal care and homemaker services (see later revisions in 2024).

Home Health services are not covered solely to allow a caregiver to work or attend school. A lack of an available caregiver does not convert an otherwise non-skilled service into a skilled service, nor does it by itself establish medical necessity for skilled services.

This payment policy is provided for information and operational guidance only and is not a guarantee of reimbursement. Claim payments remain subject to member eligibility, Neighborhood benefit coverage, claims-edit rules, coding and documentation requirements, authorization policies, provider contract terms, and applicable state and federal regulations; all billed services are subject to audit.

Codes, Modifiers, and EVV

Skilled and Non-Skilled HCPCS/CPT Codesmixed

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 billed)
S5125-U9	High acuity attendant care services; per 15 minutes
S5130	Homemaker service, NOS; per 15 minutes
S9097	Home visit for care of wound
S9127	Social work visit, in the home, per diem
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

1–10 of 17

1/2

Applicable ModifiersModifier

U1	Combination of personal care and homemaking; must be included when billed
U9	High acuity modifier
TV	Weekend / Rhode Island State Holiday Shift
UH	Evening Shift 3 PM - 11 PM
UJ	Night Shift 11 PM - 7 AM

Home Health / Hospice Service CodesmixedCovered

G0151	Physical therapy services in home health/hospice, per 15 minutes
G0153	Speech-language pathology services in home health/hospice, per 15 minutes
G0156	Home health/hospice aide services
S9097	Home visit for wound care

Modifiers (billing notes)Modifier

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

PDN continuous skilled care — threshold definition (>2 hours/day requires RN/LPN)

PDN continuous skilled care thresholdContinuous skilled care > 2 hours/day requires RN or LPN per practice standards

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Private Duty Nursing (PDN). Submit requests with the physician-signed plan of care and the two most recent nursing notes to facilitate medical necessity review. Neighborhood utilizes the InterQual Private Duty Nursing (PDN) Assessment to determine the clinically appropriate range of PDN hours. Authorizations for PDN are issued for a maximum 13-week period and must be renewed thereafter.

Prior authorizations required every 13 weeks
Include physician-signed plan of care and two most recent nursing notes
InterQual PDN Assessment used to determine hours

Note

Authorization Subject to Plan Rules

Authorization and payment are subject to member eligibility, Neighborhood Health Plan of Rhode Island benefit coverage, provider contract terms, claims editing rules, coding and documentation guidelines, and state and federal regulations. Providers are responsible for verifying eligibility and coverage prior to rendering services.

Coverage/payment subject to member eligibility and plan benefits

Key Definitions and Operational Terms

Home / Home Setting — definition of home vs institutional settings

Definition of HomeA home is any place where the member has established residence for the period when home care services are provided (own dwelling, apartment, home of friend/family, group home, homeless shelter, or other temporary residence)

Exclusions from Home SettingInstitutional facilities (hospitals, skilled nursing facilities, intermediate care facilities, or any other institutional facility providing medical/nursing/rehabilitative care) are not considered a home setting

Other non-home settingsAdult care settings or adult medical care settings do not meet the definition of a home setting

Private Duty Nursing (PDN) — definition of continuous skilled care, billing units, intended purpose

Definition of PDNPrivate Duty Nursing (PDN) is individual, continuous skilled nursing care provided by licensed nurses for members with complex medical conditions managed at home

Background and Scope

Home Health and Home Care services encompass both skilled services (such as skilled nursing and therapy delivered per a physician/NPP-authorized plan of care) and non-skilled services (including home health aide, attendant care, homemaking, and personal care). Services may be intermittent or continuous and must be provided within the provider’s scope of licensure; Private Duty Nursing (PDN) is continuous individual skilled nursing billed by the hour for members with complex conditions and is covered only when PDN medical-necessity criteria are met.

Document Revision History

2024-09-18policy_revisionLatest

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

2024-07-01policy_revision

Defined personal care and homemaker services and clarified Rhode Island holiday use for TV modifier.

2024-01-01coding_update