CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

MDS Home Care Member Acuity Enhanced Reimbursement

Defines high-acuity scoring from the Minimum Data Set (MDS) for Home Care and the process for agencies to receive an enhanced reimbursement ($1.00/hour) for Combined Personal Care/Home Maker Services for Neighborhood Health Plan of Rhode Island Integrity members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMDS Home Care Member Acuity Enhanced Reimbursement

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed MDS Home Care form signed by an R.N. to Neighborhood's Utilization Management to obtain authorization and enable the $1.00/hour enhanced reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$1.00/hrenhanced reimbursement amount for qualifying high-acuity members

4 thresholdssingle-area threshold options

4 combostwo-area combination options

U9billing modifier

High-Acuity Eligibility and Criteria

High Acuity Eligibility Criteria and Actions

A member is eligible for enhanced reimbursement when assessed as high acuity by the agency Registered Nurse using the MDS Home Care scoring thresholds. The agency must submit the completed, RN-signed MDS form to Neighborhood's Utilization Management (UM) Department; UM will enter authorization to allow the enhanced payment and Medical Management will monitor entries.

ONE of the following single-area minimum scores

Section B (Items 1, 2, and 3) total = 5
Section E, Item 1 total = 16
Section E, Items 2 and 3 total = 8
Section H, Items 1, 2 and 3 total = 36

OR meet minimum scores in TWO or more areas (two-area combination)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMDS Home Care Member Acuity Enhanced Reimbursement

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed MDS Home Care form signed by an R.N. to Neighborhood's Utilization Management to obtain authorization and enable the $1.00/hour enhanced reimbursement.

SourceLink

On This Page

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Billing Modifier and Acuity Thresholds

Acuity modifierModifierCovered

U9	Modifier to bill enhanced payment for high-acuity members

Single-area high acuity thresholds

Section B (Items 1-3)Minimum score of 5 on Section B, Items 1, 2 and 3

Section E (Item 1)Minimum score of 16 on Section E, Item 1

Section E (Items 2 & 3)Minimum combined score of 8 on Section E, Items 2 and 3

Section H (Items 1-3)Minimum combined score of 36 on Section H, Items 1, 2 and 3

Two-area combined thresholds

Section B (Items 1-3)Minimum score of 3 on Section B, Items 1, 2 and 3 when combined with a second qualifying area

Section E (Item 1)Minimum score of 8 on Section E, Item 1 when combined with a second qualifying area

Section E (Items 2 & 3)Minimum combined score of 4 on Section E, Items 2 and 3 when combined with a second qualifying area

Section H (Items 1-3)Minimum combined score of 18 on Section H, Items 1, 2 and 3 when combined with a second qualifying area

Authorization, Documentation, and Billing Steps

Prior Authorization

Submit RN‑signed MDS to UM and bill with modifier U9

Submit a completed MDS Home Care form for each Integrity member who meets high‑acuity criteria to Neighborhood's Utilization Management (UM) Department. The MDS must be signed by an R.N., dated, and totaled for each section; upon receipt UM will enter an authorization to enable the $1.00/hour enhanced reimbursement. Claims for members meeting the acuity standard must be billed with modifier U9 (some claims may require two modifiers if services occur evenings/nights/weekends/holidays).

Complete the MDS Home Care form for Integrity members meeting the high‑acuity thresholds.
Ensure the MDS is signed by an R.N., dated, and totaled for each section.
Submit the completed MDS directly to Neighborhood's UM Department for authorization entry.
Bill qualifying claims with modifier U9; include a second modifier when applicable for evenings/nights/weekends/holidays.

Key Terms

MDS Home Care form

Form nameMinimum Data Set (MDS) for Home Care

PurposeStandardized assessment form used by agency R.N. to score behavior/function over the past 7 days to determine member acuity for enhanced reimbursement

Completion requirementsMDS must be signed by an R.N., dated, and totaled for each section before submission to Neighborhood's UM Department

AvailabilityMDS Home Care Form is available on Neighborhood's website under Providers/Resources and FAQs/Medical Services - Medical Management Request Forms

Integrity members

DefinitionIntegrity members are the only members for whom the MDS Home Care form is collected and submitted to receive the enhanced reimbursement

Submission requirementAgency must submit MDS data on all Integrity members to Neighborhood's Utilization Management (UM) Department to obtain authorization for the enhancement

Authorization effectUpon receipt of a completed MDS for eligible Integrity members, an authorization will be entered into the system to allow the enhanced payment