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Home Health, Skilled, and Custodial Care Services (for Idaho Only)
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State-specific UnitedHealthcare Community Plan policy governing coverage, codes, and criteria for home health, skilled, and custodial care services for members in Idaho (including Idaho Medicaid Plus). Affects providers submitting claims and requesting authorization for home-based services in Idaho.
Added notation that a long list of HCPCS/T codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program.
Removed reference link to the Medical Policy titled Applicable Codes.
Removed reference link to the Medical Policy titled Home Hemodialysis (for Idaho Only).
Coverage Criteria
Non‑state‑specific medical necessity
Covered when InterQual LOC criteria for Home Care Services, Adult indicate medical necessity.
Provider must apply InterQual clinical criteria for non-state-specific medical necessity
State‑specific coverage
Coverage and limitations are determined by the Idaho Medicaid Provider Handbook.
State-level rules govern coverage specifics for Idaho Medicaid Plus members
General medical necessity for home health services
Covered when services are prescribed and medically necessary.
Services are provided intermittently to restore or maintain the member's maximal level of function; skilled services must be furnished by licensed health care professionals; custodial care is nonmedical assistance as defined.
A Place of Residence for Home Health Services is any non‑institutionalized setting in which normal life activities take place. It does not include settings where payment is or could be made under Medicaid for inpatient services that include room and board (for example, hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities), except as limited by federal regulation (CFR § 440.70).
HCPCS and other procedure codes in this policy that are labeled with an asterisk (*) are identified as not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the Idaho Medicaid Program. Providers should refer to the Idaho Medicaid Provider Handbook for details on non‑covered and excluded services before billing or requesting authorization.
Listing a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is covered. Benefit coverage and reimbursement rights are determined by applicable federal, state, or contractual requirements and other policies; inclusion in this document is not a guarantee of payment.
For informational purposes only: FDA approval alone is not a basis for coverage. Home health and skilled home care services are delivered by licensed health care professionals and are not regulated by the U.S. Food and Drug Administration; FDA status does not determine benefit coverage under this policy.
Coding and Applicable Codes
| 99500 | Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring. |
| 99501 | Home visit for postnatal assessment and follow-up care. |
| 99502 | Home visit for newborn care and assessment. |
| 99503 | Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation). |
| 99504 | Home visit for mechanical ventilation care. |
| 99505 | Home visit for stoma care and maintenance including colostomy and cystostomy. |
| 99506 | Home visit for intramuscular injections. |
| 99507 | Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral). |
| 99511 | Home visit for fecal impaction management and enema administration. |
| 99601 | Home infusion/specialty drug administration, per visit (up to 2 hours). |
| G0068 | Professional services for administration of certain IV infusion drugs or biologicals in the home, each 15 minutes. |
| G0069 | Professional services for administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological in the home, each 15 minutes. |
| G0070 | Professional services for administration of intravenous chemotherapy or other highly complex infusion in the home, each 15 minutes. |
| G0152 | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. |
| G0153 | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. |
| G0155 | Services of clinical social worker in home health or hospice settings, each 15 minutes. |
| G0156 | Services of home health/hospice aide in home health or hospice settings, each 15 minutes. |
| G0157 | Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes. |
| G0158 | Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes. |
| G0160 | Services performed by a qualified physical therapist in the home health setting in establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. |
| G0161 | Services performed by a qualified physical therapist in the home health setting in establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes. |
| G0162 | Skilled services by a registered nurse (RN) for management and evaluation of the plan of care, each 15 minutes when RN required to ensure essential nonskilled care achieves its purpose. |
| G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes. |
| G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health setting, each 15 minutes. |
| G0320 | Home health services furnished using synchronous telemedicine via real-time audio and video. |
| G0321 | Home health services furnished using synchronous telemedicine via real-time interactive audio-only. |
| G0322 | Collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (remote patient monitoring). |
| G0493 | Skilled services of an RN for observation and assessment of the patient's condition, each 15 minutes when change requires skilled nursing personnel. |
| G0494 | Skilled services of an LPN for observation and assessment of the patient's condition, each 15 minutes when change requires skilled nursing personnel. |
| H1004 | Prenatal care, at-risk enhanced service; follow-up home visit. |
| S5035 | Home infusion therapy, routine service of infusion device (e.g., pump maintenance). |
| S5036 | Home infusion therapy, repair of infusion device (e.g., pump repair). |
| S5108 | Home care training to home care client, per 15 minutes. |
| S5109 | Home care training to home care client, per session. |
| S5110 | Home care training, family; per 15 minutes. |
| S5111 | Home care training, family; per session. |
| S5115 | Home care training, nonfamily; per 15 minutes. |
| S5116 | Home care training, nonfamily; per session. |
| S5180 | Home health respiratory therapy, initial evaluation. |
| S5497 | Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, per diem. |
| S5498 | Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination, per diem. |
| S5501 | Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, per diem. |
| S5502 | Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination, per diem. |
| S5517 | Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting. |
| S5518 | Home infusion therapy, all supplies necessary for catheter repair. |
| S5520 | Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (PICC) line insertion. |
| S5521 | Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion. |
| S5522 | Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC), nursing services only (no supplies or catheter included). |
| S5523 | Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included). |
| S9325 | Home management of postpartum hypertension, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem. |
| S9331 | Home infusion therapy, intermittent (less than 24 hours) chemotherapy infusion; includes administrative services, professional pharmacy services, care coordination, per diem. |
| S9336 | Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin); includes administrative services, professional pharmacy services, care coordination, per diem. |
| S9340 | Home therapy; enteral nutrition; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem. |
| S9341 | Home therapy; enteral nutrition via gravity; includes administrative services, professional pharmacy services, care coordination, per diem. |
| S9342 | Home therapy; enteral nutrition via pump; includes administrative services, professional pharmacy services, care coordination, per diem. |
| S9343 | Home therapy; enteral nutrition via bolus; includes administrative services, professional pharmacy services, care coordination, per diem. |
| HCPCS (various) | Home infusion therapy codes for antihemophilic agents, alpha-1-proteinase inhibitor, uninterrupted long-term controlled rate infusions, sympathomimetic/inotropic agents, antiemetic infusion, continuous insulin infusion, chelation, enzyme replacement, etc., each described as per diem administrative/professional pharmacy/care coordination services. |
| S9343 | Home management of postpartum hypertension, includes administrative services, professional |
| S9365 | Home infusion codes referenced (do not use with S9365-S9368 using daily volume scales) - listed in context |
| S9377 | Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies |
| S9379 | Professional pharmacy services, care coordination, and all necessary supplies |
| S9474 | Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem |
| S9497 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination |
| S9500 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours |
| S9501 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours |
| S9502 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours |
| S9503 | Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours |
| 99500 | Listed as not on Idaho Medicaid Fee Schedule |
| 99501 | Listed as not on Idaho Medicaid Fee Schedule |
| 99502 | Listed as not on Idaho Medicaid Fee Schedule |
| 99503 | Listed as not on Idaho Medicaid Fee Schedule |
| 99504 | Listed as not on Idaho Medicaid Fee Schedule |
| 99505 | Listed as not on Idaho Medicaid Fee Schedule |
| 99506 | Listed as not on Idaho Medicaid Fee Schedule |
| 99507 | Listed as not on Idaho Medicaid Fee Schedule |
| 99511 | Listed as not on Idaho Medicaid Fee Schedule |
| 99601 | Listed as not on Idaho Medicaid Fee Schedule |
Provider Actions and Billing Guidance
Use InterQual LOC: Home Care to determine medical necessity
Medical necessity for home health and skilled care services must be determined using the InterQual LOC: Home Care Q&A: Home Care Services, Adult criteria; providers should apply InterQual clinical criteria when assessing necessity.
Check benefit‑specific authorization and prior‑auth rules
Verify the applicable federal, state, or contractual benefit requirements and the member’s plan rules before providing services — this policy is informational and benefit-specific rules govern; prior authorization requirements are determined by the plan and contractual rules.
- Check the member’s benefit and plan-specific prior authorization requirements before scheduling services.
- If plan or contractual requirements conflict with this policy, the federal, state, or contractual terms govern.
Refer to Idaho Medicaid Provider Handbook for state‑specific coverage
For state‑specific covered services, limits, and non‑covered items for Idaho members, refer to the Idaho Medicaid Provider Handbook, Provider Guidelines, Home Health and Hospice Services: Home Health: Covered Services and Limitations.
- State-level coverage limits and exclusions in the Idaho handbook supersede non‑state policy language for Idaho Medicaid members.
Administrative note — follow plan instructions and tools
Administrative note: follow plan instructions for use and confirm whether third‑party tools (e.g., InterQual) are required or referenced by the plan when determining coverage.
Confirm member’s place of residence meets policy definition
Place of Residence for Home Health Services is any non‑institutionalized setting where normal life activities take place; do not consider settings where payment is or could be made under Medicaid for inpatient services (e.g., hospital, nursing facility, ICF/IID) as a place of residence, except as limited by CFR § 440.70.
- If federal, state, or contractual definitions differ, those definitions supersede this policy.
Obtain practitioner prescription and ensure qualified providers deliver services
Home health services must be prescribed by a treating practitioner or specialist (MD, DO, PA, or NP) and delivered in the member’s residence; skilled services must be furnished by licensed health care professionals.
- Ensure an appropriate practitioner’s order is on file before initiating services.
- Document that skilled services are provided by licensed clinicians as described in the plan of care.
Code listing does not guarantee coverage or payment
Listing a procedure or HCPCS/CPT code in this policy is for reference only and does not imply that the service described by the code is covered or guarantees payment; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.
- Do not assume coverage or payment solely because a code appears in this policy; verify member benefits and applicable program rules.
Asterisked HCPCS codes may be non‑covered and denied
Codes in this policy marked with an asterisk (*) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program; using these non‑covered HCPCS codes may result in claim denial.
- Before billing, confirm the code’s status on the Idaho Medicaid Fee Schedule and the Idaho Medicaid Provider Handbook non‑covered services list.
- Avoid billing asterisked HCPCS codes for Idaho Medicaid members unless handbook or payer guidance indicates coverage.
Background
Home health services include skilled nursing, rehabilitative therapies, infusion and specialty drug administration, and other supportive home‑based services delivered in a non‑institutional residence. These services are intended to support recovery after illness, injury, surgery, or hospitalization and to help manage chronic conditions so as to prevent or shorten inpatient stays. Clinical medical necessity for skilled home care is determined using InterQual criteria where applicable, and state‑specific covered services and limitations for Idaho are governed by the Idaho Medicaid Provider Handbook.
Definitions
Revision History
Added notation that a long list of specific HCPCS/T codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the Idaho Medicaid Program; archived previous policy version CS137ID.C.
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