CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Home health care services coverage and reimbursement

Governs Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for skilled and non-skilled home health care services across specified lines of business and provider responsibilities.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome health care services coverage and reimbursement

Policy CodePolicy N/A

Change TypeDocument updatesclarification adding Commercial exclusion

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements before rendering home health services.

SourceLink

POLICY UPDATE CHANGES

11/03/20, Action = Update: Add exclusion language for Commercial LOB.

04/08/20, Action = Document Update.

02/03/20, Action = Document Update.

48/96 hrspostpartum early discharge visit windows (vaginal/C-section)

90 daysclaim submission timeframe

7 daysmaximum date-span billing window for non-skilled services

All linesphysician's order required for skilled services

Disclaimer

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

policy is informational and not a guarantee of reimbursement

Coverage Criteria and Policy Scope

Coverage summary and exclusions

Summary of coverage by service type and line of business

Medically necessary skilled and non-skilled home health services are covered when provided within the scope of state licensure and authorized by a home care plan.

A physician's order is required for skilled services for all lines of business.

Exclusions: The following items are excluded from coverage under the Home Care Services Benefit: drugs and biologicals; services that would not be covered if furnished as inpatient services; services covered under the ESRD program; prosthetic devices; medical social services provided to family members; respiratory care services; dietary and nutritional personnel when not incidental to the plan of care.

RIte Care / RHE specific: Combination services and respite/relief care are non-covered under RIte Care/RHE.

INTEGRITY specific: Services under a home care plan must be provided by a Medicare-certified home health agency for covered home care plan services; non-skilled services and private duty nursing may be delivered by agencies that are not Medicare-certified. Non-skilled services do not require a physician's order.

Commercial specific: Homemaker services and combination services are non-covered for Commercial line of business.

Coverage and billing rules (section-specific)

Claims/payment subject to plan and administrative rules; policy informational only.

Payments are subject to member eligibility, benefit coverage, coding and documentation requirements, claims payment edit rules, authorization policies, provider contract agreements, and applicable state and federal regulations.

Per-diem and code combination rules: Per-diem codes exist for many home infusion and home therapy services; do not combine certain daily codes as noted (for example, S9364 is not to be used with S9365-S9368).

Modifier billing: When billing combination services with shift and acuity modifiers, include the U1 modifier each time the combination service is billed; the shift differential modifier must precede the acuity modifier.

Code usage notes: Some codes have specific usage restrictions (for example, S9373 not to be used with S9374-S9377 hydration codes; S9494 not to be used with hourly dosing schedule codes S9497-S9504).

General payment constraints

General stance and constraints on reimbursement

This payment policy is informational only and is not intended to address every reimbursement situation; it is not a guarantee of payment.

Claim payments remain subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations.

Neighborhood may implement the policy differently across its electronic claims processing systems due to programming or other constraints; Neighborhood reserves the right to update this payment policy at any time and all services billed are subject to audit.

Codes, Billing Windows, and Coding Rules

Home health service codesmixed

99500-99507, 99510	Home visit codes for prenatal/postnatal/newborn/various skilled nursing and social work visits
G0068-G0070, G0154, G0299, G0300, G0493-G0496, G0160-G0161, G0159	Home infusion/therapy and skilled nursing time-based Medicare G-codes
S5108-S5180, S9097-S9124, S9127-S9131, S9129-S9128	Home care training, respiratory, wound care, per diem home therapy and nursing private duty codes
T1001-T1031, T1502-T1503	Nursing assessment and short-interval RN/LPN services and medication administration
97001-97002, 97140, 97161-97164, 97165-97168, 97530, 97532-97535	Physical and occupational therapy evaluation, re-evaluation, and treatment CPT codes
92506-92524, 92597, 92610, 97526	Speech therapy and swallowing evaluation/treatment codes

Skilled Occupational Therapy codes (examples)CPTCovered

97003	Occupational therapy evaluation
97165	Occupational therapy evaluation; low complexity, 30 minutes
97530	Therapeutic activities, direct (one-on-one) patient contact

Skilled Speech Therapy codes (examples)CPTCovered

92506	Evaluation of speech, language, voice, communication, and/or auditory processing
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92610	Evaluation of oral and pharyngeal swallowing function

Home IV/enteral/parenteral infusion and supply codes (examples)HCPCSCovered

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty drug administration, each additional hour
B4150	Enteral formula, nutritionally complete with intact nutrients, 100 calories = 1 unit
B4172	Parenteral nutrition solution; amino acid, 5.5%-7%, 500 ml =1 unit - home mix
B9002	Enteral nutrition infusion pump
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, per diem

Early maternity discharge and non-skilled servicesmixedCovered

99501	Home visit for postnatal assessment and follow-up care
T1030	Nursing care, in the home, by registered nurse, per diem
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes
S5125	Home Health Aide (HHA) or Certified Nursing Assistant providing care in the home, per 15 minutes

Coding referencesmixed

No codes listed

Date-span billing limit (non-skilled)

Maximum spanDates of service are limited to one week (7 days) per claim line.

Consecutive servicesServices must have been provided consecutively on each date within the span; any break requires a new claim line.

Same month requirementDates of service in a date span must be within the same month.

Multiple shifts same dayMultiple shifts on the same day must be billed on the same claim line with a cumulative of all hours for that date of service.

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

Provider Responsibilities, Authorization, and Billing Caveats

Prior Authorization

Prior Authorization Requirements

Prior authorization requirements vary by line of business and specific services. Providers must verify member eligibility, benefit coverage and obtain any required prior authorization before rendering services.

Refer to Neighborhood's plan-specific Prior Authorization Reference page.
Refer to Neighborhood's Clinical Medical Policies; in the absence of a clinical policy, Neighborhood may use industry-accepted criteria, National or Local Coverage Determinations, and/or EOHHS regulations.
Contact Provider Services at 1-800-963-1001 for additional details.

Billing Rule

Billing/Authorization Caveats

Claims are subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. This policy is informational and is not a guarantee of reimbursement.

Definitions and Shift/Service Terms

Home Health Care services

DefinitionHome Health Care services are provided under a home care plan authorized by a health care professional and include full-time, part-time, or intermittent skilled and non-skilled services delivered by a Home Health Agency.

ScopeCoverage is provided for services performed within the scope of state licensure as defined by the Rhode Island Department of Health.

EVV applicabilityPersonal care services and home health care services that require an in‑home visit must use an electronic visit verification (EVV) system pursuant to section 1903(l) of the Cures Act.

Electronic Visit Verification (EVV)

RequirementProviders must use an electronic visit verification (EVV) system for personal care services and home health care services that require an in‑home visit as required by section 1903(l) of the Cures Act.

Applies to

Document History and References

2020-11-03update

Added exclusion language for Commercial line of business.

2020-04-08document_update

General document update.

2020-02-03document_update

General document update.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome health care services coverage and reimbursement

Policy CodePolicy N/A

Change TypeDocument updatesclarification adding Commercial exclusion

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements before rendering home health services.

SourceLink

On This Page

Informational disclaimer: This policy is informational only and not a guarantee of reimbursement; Neighborhood may update payment policy at any time and payments are subject to audit.

TPN daily volume tiers

S9365Home infusion therapy, total parenteral nutrition (TPN); one liter per day, per diem.

S9366Home infusion therapy, TPN; more than one liter but no more than two liters per day, per diem.

S9367Home infusion therapy, TPN; more than two liters but no more than three liters per day, per diem.

S9368Home infusion therapy, TPN; more than three liters per day, per diem.

All services billed to Neighborhood for reimbursement are subject to audit.
References to CPT or other sources are for definitional purposes only.
Policy implementation may vary across Neighborhood's electronic claims processing systems.

Denial Risk

Claims Payment Prerequisites

Payment of claims requires documentation and coding that support medical necessity and adherence to authorization requirements. Payments may be denied, adjusted or recovered if claims do not meet Neighborhood's coverage rules, coding/documentation standards, authorization policies, or if member eligibility is not verified at the time of service.

Ensure medical necessity is documented in the medical record.
Maintain and produce supporting documentation upon request for audits or post-payment review.
Verify and retain evidence of prior authorization where required.

EVV applies to personal care and home health services requiring in‑home visits provided by Neighborhood Health Plan of Rhode Island providers.

AuthorityMandated by the State of Rhode Island Executive Office of Health & Human Services (EOHHS) implementation of the Cures Act requirement.

Weekend/Federal Holiday Shift

Code/ModifierTV

MeaningWeekend/Federal Holiday Shift.

Usage noteShift differential modifier (e.g., TV) must precede acuity modifier when both are applicable for combination services.

Evening Shift 3PM -11PM

Code/ModifierUH

MeaningEvening Shift 3PM - 11PM.

Usage noteWhen billing combination services with shift and acuity modifiers, include modifiers in the order: shift differential before acuity.

Night Shift 11PM-7AM

Code/ModifierUJ

MeaningNight Shift 11PM - 7AM.

Usage noteShift differential modifiers (e.g., UJ) must precede acuity modifiers when both apply to combination services billing.

Health Care Professional

Scope'Health Care Professional' is defined in the referenced CMS/RI EOHHS/NHPRI contract to include physicians and other providers such as podiatrists, optometrists, psychologists, dentists, physician assistants, therapists, nurses, social workers, respiratory therapists, and others.

Contract referenceDefinition sourced from the Contract between CMS, RI EOHHS, and NHPRI as listed in References.

ApplicabilityTerm applies to authorization and home care plan requirements within this policy.

Private Duty Nursing

Definition'Private Duty Nursing' is defined in the referenced contract as individual and continuous care (in contrast to part‑time or intermittent care) provided by licensed nurses within the scope of State law and as identified in the LTSS Care Plan, delivered to an enrollee at home.

Contrast to other carePrivate Duty Nursing denotes continuous individual care rather than part‑time or intermittent services.

SourceDefinition provided in the Contract between CMS, RI EOHHS, and NHPRI (References).

2017-07-01effective_dateLatest

Policy effective date.

This payment policy is informational only and 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, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. The policy may not address every reimbursement situation and Neighborhood may update the policy at any time; all services billed to Neighborhood are subject to audit.

Providers must verify eligibility, benefit coverage, and any required authorizations with the member's plan prior to rendering services. References to CPT, HCPCS, or other coding sources within this policy are provided for definitional purposes only and do not, by themselves, assure payment.

References: Contract between CMS, RI EOHHS, and NHPRI (definitions for 'Health Care Professional' and 'Private Duty Nursing'), RIGL 17-23-4, 42 CFR Part 484 (Conditions of Participation: Home Health Agencies), and related state regulations and contract provisions cited in the plan references.