Home Health Services — Reimbursement Policy
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Governs reimbursement policy for home health services (place of service 12) for Select Health of South Carolina members, including prior authorization, visit limits, and documentation requirements for providers billing on CMS-1500 or UB-04 forms.
Added home infusion therapy definition.
Updated reimbursement language.
Added associated policy reference to Durable Medical Equipment, Prosthetics, Orthotics and Supplies (RPC.0074.2400).
Home Health Coverage Criteria
Home health coverage criteria
Home health services are covered when all of the following medical necessity, ordering, visit-limit, and prior authorization requirements are met:
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- Services must be ordered by a physician as part of a written Select Health plan of care.
- The ordering provider must review and sign the Select Health plan of care at least every 60 days.
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- Services must be for homebound members when needed to restore or maintain maximum function and be medically necessary.
- Skilled nursing services must be prescribed by a physician and be medically necessary for the member's illness or injury.
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- Members are limited to 50 home health visits per fiscal year.
- Home social work services received from Family Support Services (FSS) do not apply to the 50-visit limitation.
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- Trigger for prior authorization: Prior authorization is required after the first six home health visits.
- Home-based services requiring authorization: Home-based services require prior authorization including home health therapies (physical, occupational, speech), home health aides, and skilled nursing after 18 combined visits regardless of modality.
- One authorization will cover all services rendered (visits, therapies, supplies, etc.) on the authorized date(s); a separate authorization is not required for each service.
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- The Select Health plan of care should document goals, needs, care rendered, services, supplies or personnel needed, expected outcomes, and restrict care to the minimum number of visits necessary to meet objectives.
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- Home health care services are not reimbursable for POS 12 during an inpatient stay.
- Services rendered on dates of inpatient admission and discharge may be reimbursed as an exception.
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- Policy applies to services billed on CMS-1500 or UB-04 forms or electronic equivalents; code listings are for reference and do not guarantee coverage.
Coding, Limits, and Prior Authorization Triggers
| No codes listed |
Prior Authorization and Provider Requirements
Prior authorization required after six visits; one authorization covers all services
Prior authorization is required after the first six home health visits. One authorization will cover all services rendered (visit, therapies, supplies, etc.) on the date(s) authorized; a separate authorization is not required for each service. Home-based services (home health care therapies, home health aides, and skilled nursing after 18 combined visits) also require prior authorization.
- Trigger: prior authorization required after first six visits
- Scope: one authorization covers all services on the authorized dates (visits, therapies, supplies)
- Home-based services listed (PT/OT/SLP, home health aides, skilled nursing after 18 combined visits) require prior authorization
Population Health prior authorization for homebound members
Homebound members require prior authorization from the Select Health Population Health department. The home health authorization includes physical, occupational, and speech home visits and does not require separate authorizations for each of these services.
- Authorization source: Select Health Population Health department
- Included services: physical, occupational, and speech home visits
- No separate authorization needed for each included service
Exception: reimbursement allowed on inpatient admission/discharge dates
Home health care services rendered on the dates of inpatient admission and discharge may be reimbursed despite the general non-reimbursable rule during an inpatient stay.
- General rule: home health services are not reimbursable for POS 12 during an inpatient stay
- Exception: services on dates of inpatient admission and discharge may be reimbursed
Definitions
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