CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health & Hospice Prior Authorization and Coverage Requirements

Defines documentation, authorization, and coverage requirements for skilled intermittent home health, non-skilled home care, and private duty nursing services for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health & Hospice Prior Authorization and Coverage Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the HHA prior authorization form to Utilization Management for home care services unless exempted by the first 6 visits rule.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections A-Cservice categories covered (Skilled, Non-skilled, PDN)

First 6 visitsno auth for first visits

CMS-485/OASISrequired documentation

Hours/weekPDN hours requirement

Coverage criteria for home health services

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Continuation of Skilled Home Health

Covered when ALL of the following are met

Skilled continuation requirements: Current CMS-485 Home Health Certification and Plan of Care (CMS-485) signed by agency clinician that received verbal orders for the plan of care and/or signed by the practitioner; AND current completed OASIS with documentation of verbal orders received for all requested visits; AND supporting documentation of the member's need for skilled home health services such as evaluations, assessments, and progress notes for each requested discipline

Recertification Criteria

Recertification covered when ALL of the following are met

Recertification assessment/evaluation for each requested discipline that addresses progress toward goals with objective measurements, response/barriers to education and managing care, and adherence issues; dates of service cannot overlap certification periods; include discipline-specific information and requested number of visits as indicated on the recertification form (e.g., T1030/T1031 for skilled nursing; G0151/G0152/G0153 for therapies; S9127 for social work; G0156 or S5125 for home health aide).

Non-Skilled Home Care Criteria

Covered when ALL of the following are met

Home care documentation: Services are part of a physician's plan of care (orders, letter of necessity, referral); for new start or increased services provide documentation of level of assistance with ADLs/IADLs (MDS for Home Care signed by a nurse within 90 days or Provider Medical Statement from physician within 1 year); provide current aide plan of care and explanation of need for the requested visits; include requested number of hours per week when applicable; Integrity (MMP) requests must match care manager–approved hours and services

Regulatory T1001 visits: first 6 visits per member per agency in a rolling year do not require authorization

Private Duty Nursing Criteria

Covered when ALL of the following are met

PDN requirements: Current comprehensive Plan of Care (POC) signed by agency clinician that received verbal orders for the plan of care and/or signed by the physician; ongoing physician supervision for all PDN requests; provide up to two weeks of the most recent nursing notes detailing nursing interventions and care provided during shifts; if applicable provide complete wound description (depth, drainage, type, size) and wound care orders; document requested number of hours per week; change-in-condition or caregiver status increases require supporting documentation

Regulatory T1001 visits: first 6 visits per member per agency in a rolling year do not require authorization

Service and procedure codes, and authorization exemptions

Referenced service and procedure codesmixed

T1030	Skilled nursing related code (documented on form)
T1031	Skilled nursing related code (documented on form)
G0151	Physical Therapy
G0152	Occupational Therapy
G0153	Speech Therapy
S9127	Social Worker
G0156	Home Health Aide (MED or MMP)
S5125	Home Health Aide (Commercial) / Combination Services
T1001	Nursing Evaluations/Assessments
T1002	Private Duty Nursing code option

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Prior authorization codes (used in prior auth requirement)mixed

G0151	Physical Therapy
G0152	Occupational Therapy
G0153	Speech Therapy
S9127	Social Worker
G0156	Home Health Aide (MED or MMP)
S5125	Home Health Aide (Commercial) / Combination Services
T1030	Skilled nursing related code (documented on form)
T1031	Skilled nursing related code (documented on form)
T1001	Nursing Evaluations/Assessments
T1002	Private Duty Nursing code option

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Authorization exemption — First 6 visits

Exemption ruleNo authorization required for the first 6 visits per member, per agency in a rolling year

Applies toRegulatory nursing evaluations/assessments (T1001)

Timeframe noted in form sectionsDates of service ranges are captured on the form (not to exceed 26 weeks per one section; rolling year language also used)

ScopePer-member, per-agency — applies separately for each member and each agency providing services

Reference contextReferenced under Continuation of Services and New Start/Continuation of Care sections of the prior authorization form

Prior authorization, documentation, and submission guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for home care services. Submit the completed Home Care Services Prior Authorization Form to Utilization Management (Fax: 401-459-6023). Indicate if HHA hours are requested.

Submit completed HHA prior authorization form to Utilization Management
Fax: 401-459-6023

Note

Provider action

Complete all fields on the prior authorization form and include all supporting clinical documentation. Requests submitted without clinical information will be returned as incomplete and will delay processing.

Documentation Required

Required clinical documentation

For continuation of skilled services, provide a current CMS-485 signed by the agency clinician who received verbal orders for the plan of care and/or signed by the practitioner; AND a current completed OASIS with documentation of verbal orders received for all requested visits; AND/OR supporting documentation such as evaluations, assessments and progress notes for each requested discipline. Include up to two weeks of the most recent nursing notes detailing interventions and care provided during the nurse's shift when applicable.

Documentation Required

Medicaid-specific documentation

For Medicaid members (RHE, RHP, MED, CSN, SUB): provide documentation that services are part of a physician's plan of care (e.g., doctor’s orders, letter of medical necessity, referral).

Denial Risk

Insufficient documentation triggers denial/return

Failure to provide sufficient information will delay processing and requests submitted without clinical information will be returned as incomplete. Per EOHHS, Neighborhood cannot pay for services provided by individuals who reside with the member, are a family member as defined by RI law, or are legally responsible for the member.

Policy background and scope

This policy establishes the administrative and clinical submission requirements for skilled intermittent home health, non‑skilled home care, and Private Duty Nursing (PDN). It requires that services be part of a physician's plan of care and supported by signed plans of care, relevant assessments, and recent clinical documentation to demonstrate medical necessity.

For continuation of skilled services, provide a current CMS‑485 signed by the agency clinician or practitioner and a current completed OASIS with documentation of verbal orders for all requested visits. Recertification requests must include discipline‑specific assessments addressing objective progress, response to education, and barriers to care, with dates of service that do not overlap certification periods.

For Medicaid requests and new starts or increased non‑skilled services, include documentation that services are part of a physician’s plan of care (orders, letter of medical necessity, or referral) and evidence of the member’s level of assistance with ADLs/IADLs (MDS within 90 days or Provider Medical Statement within 1 year). PDN requests require a current comprehensive Plan of Care signed by the agency clinician or physician, ongoing physician supervision, up to 2 weeks of recent nursing notes, wound descriptions if applicable, and the requested number of hours per week.

Note the regulatory exemption: no authorization is required for the first 6 T1001 visits per member per agency in a rolling year. Failure to provide sufficient clinical information will delay processing and may result in the request being returned as incomplete.

Definitions and service descriptors

Combination Services / High Acuity Combination Services

Definition (Combination Services)Combination Services (S5125 U1): personal care and homemaking services performed by an HHA/CNA during the same visit

High acuity optionHigh Acuity Combination Services (S5125 U1 U9) require a completed Home Care MDS form when chosen

Code examplesS5125 used for combination or CNA services; related regulatory nursing code T1001 is listed elsewhere on the form

Provider requirementWhen selecting combination/high-acuity combination services, submit the number of hours per week requested on the form

Documentation noteHigh acuity selection specifically triggers need for Home Care MDS completion

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health & Hospice Prior Authorization and Coverage Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the HHA prior authorization form to Utilization Management for home care services unless exempted by the first 6 visits rule.

SourceLink

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