CurrentUnitedHealthcarePolicy CS137OH.D

Home Health, Skilled, and Custodial Care Services (for Ohio Only)

Defines UnitedHealthcare coverage considerations and applicable codes for home health, skilled, and custodial care services for members covered under Ohio jurisdiction; references Ohio Administrative Code and InterQual criteria for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.D

Change TypeRevised

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must rely on InterQual LOC: Home Care Q&A (Adult and Pediatric) for clinical coverage criteria and follow Ohio Administrative Code Rule 5160-12-01 when InterQual does not apply.

SourceLink

POLICY UPDATE CHANGES

Applicable HCPCS codes list updated; HCPCS codes S9339 and T1031 removed.

200+procedure and supply codes listed (CPT/HCPCS/S codes/T codes)

Ohio onlyjurisdiction this policy applies to

InterQualexternal clinical criteria used for medical necessity determinations

Medical Necessity Criteria — Home Health & Skilled Care

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Medical Necessity / General Approach

Home health and skilled care services are considered medically necessary in certain circumstances; InterQual LOC: Home Care criteria (Adult and Pediatric) are used to determine medical necessity. Coverage is also governed by Ohio Administrative Code 5160-12-01.

ALL of the following

Services are prescribed by a treating practitioner or specialist (M.D., D.O., P.A., or N.P.)
Services are delivered within the member's residence
Skilled care services are medically necessary services provided in the member's place of residence by licensed healthcare professionals (examples include medical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy)
Skilled care must be provided by licensed healthcare professionals
Services are short-term and provided intermittently to restore or maintain a member's maximal level of function or to prevent or prolong hospitalization
Services are short-term and intermittent to restore/maintain function or prevent hospitalization
Medical necessity is determined using InterQual LOC: Home Care Q&A (Home Care Services, Adult and Pediatric)
If InterQual does not have applicable criteria, UnitedHealthcare Medical Policies/Coverage Determination Guidelines/Utilization Review Guidelines approved by Ohio Department for Medicaid Services may be used
Coverage and visit limitations are subject to Ohio Administrative Code Rule 5160-12-01
In event of conflict, federal/state/contractual requirements govern

Service Definitions / Distinguishing Skilled vs Custodial Care

Coverage depends on whether services are skilled (medical) versus custodial (non-medical assistance).

ANY of the following

Skilled care: medically necessary services provided by licensed professionals (examples: wound care, medication teaching, PT/OT/ST, medical or psychological evaluation, pain management, disease education and management)
Custodial care: non-medical services that provide assistance with activities of daily living, housekeeping, cooking, laundry, or supervision of self-administered medication; these services may be provided by non-licensed caregivers and are generally not considered skilled care

Applicable Procedure and Supply Codes

Listed CPT / Home Visit / Home Infusion / Home Therapy Codes (reference only)mixed

99500	Home visit for prenatal monitoring and assessment
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
99504	Home visit for mechanical ventilation care
99505	Home visit for stoma care and maintenance
99506	Home visit for intramuscular injections
99507	Home visit for care and maintenance of catheter(s)
99511	Home visit for fecal impaction management and enema administration
99601	Home infusion/specialty drug administration, per visit (up to 2 hours)

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What Providers Must Do

Documentation Required

Use InterQual criteria and OAC for medical necessity decisions

Providers must rely on InterQual LOC: Home Care Q&A (Adult and Pediatric) for clinical coverage criteria; if InterQual does not apply, UnitedHealthcare policies approved by the Ohio Department for Medicaid Services may be used. Benefit/visit limits and other requirements from Ohio Administrative Code Rule 5160-12-01 must be followed.

Documentation Required

Service prescription requirement

A treating practitioner or specialist (M.D., D.O., P.A., or N.P.) must prescribe home health services.

Clinical & Administrative Background

Home health services are short-term, intermittent services delivered in the member's residence and are prescribed by a treating practitioner or specialist (M.D., D.O., P.A., or N.P.). They are intended to help a member recover after an illness, injury, hospital stay, or surgery, or to manage a chronic condition with the goal of restoring or maintaining maximal function and to prevent unplanned hospitalization or prolong a current hospitalization.

Skilled services are medically necessary services provided in the member's residence by licensed health care professionals and may include medical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, and rehabilitative therapies such as physical, occupational, or speech therapy. In contrast, custodial care refers to non-medical assistance with activities of daily living, housekeeping, cooking, laundry, or supervision of self-administered medication and may be provided by non-licensed caregivers; custodial care is generally not considered skilled care.

Coverage and medical necessity determinations for home health and skilled care services rely on external clinical criteria — InterQual LOC: Home Care Q&A (Adult and Pediatric) — and must be applied consistent with state requirements. For members in Ohio, benefit, visit limits and provision requirements are subject to the Ohio Administrative Code Rule 5160-12-01 and, where applicable, UnitedHealthcare policies or guidelines approved by the Ohio Department of Medicaid.

Key Definitions

Definitions / Key Terms

Skilled careMedically necessary services provided in the member's residence by licensed healthcare professionals (e.g., wound care, PT, OT, ST, medication teaching).

Custodial careNon-medical services that provide assistance with activities of daily living, housekeeping, cooking, laundry, or supervision of self-administered medication; may be provided by non-licensed caregivers.

InterQual LOC: Home Care Q&APrimary clinical criteria source UnitedHealthcare uses to evaluate medical necessity for home care services (Adult and Pediatric modules referenced).

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.D

Change TypeRevised

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must rely on InterQual LOC: Home Care Q&A (Adult and Pediatric) for clinical coverage criteria and follow Ohio Administrative Code Rule 5160-12-01 when InterQual does not apply.

SourceLink

On This Page

OpenPayer

Home Health, Skilled, and Custodial Care Services (for Ohio Only)

Medical Necessity Criteria — Home Health & Skilled Care

Applicable Procedure and Supply Codes

What Providers Must Do

Clinical & Administrative Background

Key Definitions

Policy Update Changes

Home Health, Skilled, and Custodial Care Services (for Ohio Only)

Medical Necessity Criteria — Home Health & Skilled Care

Applicable Procedure and Supply Codes

What Providers Must Do

Clinical & Administrative Background

Key Definitions

Also Read

Policy Update Changes