ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Home Health Agency Services Payment Policy 09.18.24

Defines payment, coverage limits, documentation, EVV requirements, billing and coding rules for Home Health/Home Care services across Medicaid, INTEGRITY, and Commercial lines for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency Services Payment Policy 09.18.24

Policy CodePolicy N/A

Change TypeRevisions and administrative updates (definitions, coding/EVV alignment, exclusions)

Effective Date

Next Review Date

Key ActionSubmit physician-signed plan of care and most recent 2 weeks of nursing notes; prior authorizations are required every 13 weeks.

SourceLink

POLICY UPDATE CHANGES

09/18/24 Policy Review Date - Updated policy with clearer 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 to Home Health Agency Services Payment Policy and consolidated HHA coding to align with EVV requirements.

09/29/21 Policy Review Date. No Content Changes.

11/03/20 Add exclusion language for Commercial line of business.

19Listed HCPCS/Codes in Policy

6Core Clinical PDN Criteria

LOB-specific Exceptions

Policy Summary & Scope

Policy: Home Health Agency Services Payment Policy (Neighborhood Health Plan of Rhode Island). Scope: covers Home Health/Home Care services delivered by a Home Health Agency at the member's home under a physician- or non-physician practitioner–authorized written plan of care, including skilled nursing, private duty nursing (PDN), skilled therapies, and non‑skilled personal care/homemaker services. Medical necessity determinations reference NCDs, LCDs, InterQual, and RI EOHHS guidance. The policy requires providers to use an EVV system for Medicaid-funded PCS and HHCS per state implementation (Phase I for PCS; Phase II includes HHCS). Lines of business: Medicaid, INTEGRITY, and Commercial. Last review: 2024-09-18.

Key Thresholds & Scope Summary

Policy TitleHome Health Agency Services Payment Policy

PayerNeighborhood Health Plan of Rhode Island (Medicaid, INTEGRITY, Commercial)

Last Review Date2024-09-18

Has Material Changetrue

Private Duty Nursing continuous skilled care threshold> 2 hours per day

PDN Prior Authorization frequencyEvery 13 weeks

Homemaking/Personal Care weekly limit (non-LTSS individuals)Up to 6 hours/week for individuals; up to 10 hours/week for couples

Medical Necessity & Exclusions

General Medical Necessity

Services must meet ALL of the following to qualify for reimbursement:

ALL of the following

Service is medically necessary
Service is performed within the scope of state licensure as defined by the Rhode Island Department of Health
Service is provided in a home setting (member's residence, group home, homeless shelter or temporary residence) and not in institutional settings such as hospitals or skilled nursing facilities
Service is provided under a written home care plan authorized by a physician or non-physician practitioner

Codes & Modifiers

Covered / Billable Home Care HCPCS and Procedure CodesHCPCSCovered

S5125	Attendant care services; per 15 minutes. EVV Phase 1 or 2 = 1. 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. Line of Business = Medicaid & INTEGRITY.
S5125-U9	High Acuity Attendant care services; per 15 minutes. EVV Phase 1 or 2 = 1. Line of Business = All.
S5130	Homemaker service, NOS; per 15 minutes. EVV Phase 1 or 2 = 1. Line of Business = Medicaid & INTEGRITY.
S9097	Home visit for wound care. EVV Phase 1 or 2 = N/A. Skilled. Line of Business = All.
S9127	Social work visit, in the home, per diem. EVV Phase 1 or 2 = 2. Skilled. Line of Business = All.
S9128	Speech therapy, in the home, per diem. EVV Phase 1 or 2 = 2. Skilled. Line of Business = All.
S9129	Occupational therapy, in the home, per diem. EVV Phase 1 or 2 = 2. Skilled. Line of Business = All.
S9131	Physical therapy; in the home, per diem. EVV Phase 1 or 2 = 2. Skilled. Line of Business = All.
T1001	Nursing assessment/evaluation. EVV Phase 1 or 2 = N/A. Skilled. Line of Business = All.

1–10 of 18

1/2

Modifiers / Definitions referencedModifier|other

U1	Combination modifier — must be included each time S5125-U1 is billed.
TV	Weekend/Rhode Island State Holiday Shift.
UH	Evening Shift 3PM - 11PM.
UJ	Night Shift 11PM - 7AM.

Billing, Documentation & Authorization Requirements

Documentation Required

Medical record content requirements

Maintain a medical record per member that includes patient identification, referral source, physician name, plan of care, objectives, diagnoses, signed progress notes, treatment orders, changes in plan of care, advance directive documentation, and discharge summaries to support billed services.

Patient identification (name, address, birth date, gender, date of admission or readmission)
Source of patient referral
Name of physician (including address and telephone number)
Plan of care
Personal care and homemaker objectives (where applicable)
Medical diagnosis, nursing assessment, therapeutic goals, prognosis, and conditions relevant to plan of care
Drug, dietary, treatment, and activity orders
Signed and dated clinical and progress notes
Signed and dated record of service refusal
Copies of summary reports sent to the attending physician

Key Terms

Definitions

Home settingAny place where the member has established residence during the period when home care services are provided; excludes hospitals, skilled nursing facilities, and other institutional facilities.

Private Duty Nursing (PDN)Individual and continuous skilled nursing care (greater than two hours per day) provided by licensed nurses, billed per hour or block hours, intended for complex medical conditions managed at home.

EVV PhaseElectronic Visit Verification implementation designation indicating requirement phase (Phase 1 or 2) for specific services.

Policy Changes & Timeline

09/18/24revisedLatest

Material change — Policy review: Updated policy with clearer definitions for private duty nursing (PDN), non-skilled services, and limitations and exclusions.

07/01/24revised

Updated policy to define personal care and homemaker services and to define the TV modifier for Rhode Island state holidays/weekend shifts.

01/01/24revised

Material change — Administrative update: Renamed policy to 'Home Health Agency Services Payment Policy' and consolidated HHA coding to align with EVV requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Agency Services Payment Policy 09.18.24

Policy CodePolicy N/A

Change TypeRevisions and administrative updates (definitions, coding/EVV alignment, exclusions)

Effective Date

Next Review Date

Key ActionSubmit physician-signed plan of care and most recent 2 weeks of nursing notes; prior authorizations are required 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
PDN continuous skilled care threshold: The member's condition requires continuous skilled care that can only be conducted by an RN or LPN according to practice standards> 2 hours per day
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 to care for the member's condition and are in accordance with the scope of practice of a licensed nurse
Medical necessity criteria must be met within the InterQual Private Duty Nursing (PDN) Assessment; Neighborhood utilizes the InterQual PDN Assessment to determine a range of clinically appropriate PDN hours

Prior Authorization / Documentation for PDN

To facilitate medical necessity reviews and authorization: submit required documentation and note that Prior Authorizations are required every 13 weeks.

ALL of the following

Submit physician signed plan of care and the most recent 2 weeks of nursing notes with prior authorization requests
Documentation required to support PDN PA
PA frequency: Prior Authorizations are required every 13 weeksevery 13 weeks

Service Exclusions and Limitations (All Lines of Business)

Home Health services are NOT covered when ANY of the following apply:

ANY of the following

Member is a resident of a nursing facility, hospital, or licensed residential care facility
Services are provided solely to allow the caregiver to work or attend school
Services duplicate or overlap other services (see Duplication examples)
Specific excluded items: Drugs and Biologicals; Services that would not be covered if furnished as inpatient services; Services covered under ESRD program; Prosthetic Devices; Medical Social Services provided to family members; Respiratory Care Services; Dietary and Nutritional Personnel when not incidental to services required by the care plan

Duplication examples

Private duty nursing services and home health aide services cannot both be provided for the same needs
Private duty nursing services and home infusion nursing oversight services cannot both be provided for the same needs
When duplication or overlap exists, the lowest level of care needed to safely meet the member's needs may be covered

Line of Business Specific Rules

Coverage variations by line of business:

ALL of the following

Medicaid: Homemaking services are only covered when member also needs personal care services; Homemaking and Personal Care covered up to 6 hrs/week for individuals or 10 hrs/week for couples who do not meet LTSS; Respite and Relief Care are non-covered for adult members (22+); If long-term non-skilled services needed, refer to DHS for LTSS waiverUp to 6 hrs/week for individuals; up to 10 hrs/week for couples
Medicaid-specific limits and non-coverage of adult respite
INTEGRITY: Services must be provided by a Medicare certified home health agency; Homemaking and Personal Care services covered up to 6 hrs/week for individuals or 10 hrs/week for couples who do not meet LTSS; Nonskilled services do not require a physician's order; Service needs identified in CFNA covered up to 90 daysUp to 6 hrs/week for individuals; up to 10 hrs/week for couples; up to 90 days for CFNA-identified needs
INTEGRITY-specific certification and limits
Commercial: Personal care only covered if required within a skilled plan of care; Homemaker services are non-covered; Combination services are non-covered
Commercial-specific exclusions

Changes in and reviews of the patient's plan of care, signed by responsible professional

Documentation of an advance directive and copy, if provided

Prior Authorization

Prior authorization for PDN and ongoing services

Submit physician-signed plan of care and most recent 2 weeks of nursing notes; prior authorizations are required every 13 weeks.

Prior Authorizations required every 13 weeks; submit physician-signed plan of care and most recent 2 weeks of nursing notes

Billing Rule

Date span billing rules for non-skilled services

Date span billing allowed for non-skilled services up to 7 days per claim line when provided consecutively; breaks in service require new claim lines; multiple shifts same day billed on same line; dates must be within same month.

Allowed up to 7 days per claim line when services are consecutive
Any break in service requires a new claim line
Multiple shifts on the same day must be billed on the same claim line with cumulative hours for that date
Dates of service must be within the same month

Billing Rule

Date span billing prohibitions

Date span billing is prohibited for skilled services and for combination services when shift differential modifiers do not apply to each date in the span.

Billing Rule

Time-based billing and rounding

Use incremental codes for time that does not meet hourly rounding requirements; hourly codes submitted with fractional units will be denied; time-based codes must be billed for the date rendered, not the shift start date.

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 shift start date

Billing Rule

EVV requirement

Providers must use an EVV system for Medicaid-funded PCS and HHCS in accordance with state implementation (Phase I for PCS; Phase II includes HHCS); specific HCPCS codes indicate EVV Phase 1 or 2 applicability.

Specific HCPCS codes indicate EVV Phase 1 or 2 applicability (see code table)
EVV is required for Medicaid-funded Personal Care Services (PCS) and Home Health Care Services (HHCS)

Denial Risk

Claims subject to audit and denial

Claims lacking required documentation, not meeting medical necessity, billed with fractional hourly units, or billed outside timely filing guidelines may be denied or audited.

Missing or insufficient documentation to support billed services
Services not meeting medical necessity criteria
Hourly codes billed with fractional units
Claims submitted outside timely filing guidelines

Billing Rule

Combination service billing

S5125-U1 (combination personal care and homemaking) requires U1 modifier each time billed; Combination services are non-covered under the Commercial line.

S5125-U1 requires U1 modifier each time it is billed
Combination services are non-covered for Commercial line of business

09/29/21clarified

Policy review date — no content changes.

11/03/20added

Material change — Added exclusion language specific to the Commercial line of business.