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    v1.0.30
    OpenPayerPolicy UpdatesHome Health & HospiceUnitedHealthcare Home Health Policy Update | OpenP…
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    ModifiedUnitedHealthcarePolicy CS137TN1.K

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

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    This policy governs medical necessity references and applicable coding for home health, skilled care, and custodial care services provided to Tennessee Medicaid and CoverKids members.

    Policy Summary
    PayerUnitedHealthcare
    PolicyHome Health, Skilled, and Custodial Care Services (for Tennessee Only)
    Policy CodePolicy CS137TN1.K
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument the treating practitioner's or specialist's order and direction for the requested services.
    SourceLink
    POLICY UPDATE CHANGES

    HCPCS code T1005 was removed from the Applicable Codes section.

    The coverage rationale was revised to remove the prior TennCare Medicaid coverage statement and direct users to Tennessee medical necessity authorities for clinical coverage criteria.

    The coverage rationale was revised to direct Tennessee CoverKids users to InterQual home care criteria for medical necessity clinical coverage criteria.

    The References section was updated to reflect current information.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    TNApplicable state
    2Programs covered
    2Criteria sources
    100+Applicable codes
    T1005Code removed

    Coverage Criteria

    TennCare Medicaid

    For TennCare Medicaid members, apply the medical necessity clinical coverage criteria in the applicable TennCare rules and regulations.

    TennCare Medicaid medical necessity definitions and criteria are established under Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.01 (Definitions) and § 1200-13-16-.05 (Medical Necessity Criteria).

    Tennessee CoverKids

    For Tennessee CoverKids members, apply the applicable InterQual® clinical coverage criteria for home care.

    Applicable InterQual® criteria

    • Home Care Services, Adult
    • Home Care Services, Pediatric

    Home Health and Skilled Care Medical Necessity

    The requested services must meet ALL of the following criteria.

    ALL of the following

    • The services are ordered and directed by a treating practitioner or specialist (MD, DO, PA, or NP).
    • The care is delivered or supervised by a licensed professional in order to obtain a specified medical outcome.

    • The services are:

      • Not custodial care in nature.
      • Not provided for the comfort and convenience of the member or the member's family.
      • Provided in the home in lieu of skilled care in another setting, including but not limited to a nursing facility, acute inpatient rehabilitation, or a hospital.
      • Clinically appropriate and not more costly than an alternative health service.

    Custodial care is not covered under these criteria.

    Services provided for the comfort and convenience of the member or the member's family are not covered under these criteria.

    Services must be provided in the home in lieu of skilled care in another setting, including but not limited to a nursing facility, acute inpatient rehabilitation, or a hospital.

    Applicable Codes and Coding Parameters

    Applicable CodesCPT
    99500Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
    99501Home visit for postnatal assessment and follow-up care.
    99502Home visit for newborn care and assessment.
    99503Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
    99504Home visit for mechanical ventilation care.
    99505Home visit for stoma care and maintenance including colostomy and cystostomy.
    99506Home visit for intramuscular injections.
    99507Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
    99511Home visit for fecal impaction management and enema administration.
    99601Home infusion/specialty drug administration, per visit (up to 2 hours).
    1–10 of 11
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    Applicable CodesHCPCS
    G0068Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration.
    G0069Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home.
    G0070Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home.
    G0088Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
    G0089Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
    G0090Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
    G0151Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
    G0152Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
    G0153Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
    G0155Services of clinical social worker in home health or hospice settings, each 15 minutes.
    Applicable CodesHCPCS
    G0156Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
    G0157Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
    G0158Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
    G0159Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
    G0160Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
    G0161Services performed by a qualified speech-language pathologist in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.
    G0162Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes.
    G0299Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
    G0300Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.
    G0320Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system.
    1–10 of 24
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    Applicable CodesHCPCS
    S5110Home care training, family; per 15 minutes.
    S5111Home care training, family; per session.
    S5115Home care training, nonfamily; per 15 minutes.
    S5116Home care training, nonfamily; per session.
    S5125Attendant care services; per 15 minutes.
    S5180Home health respiratory therapy, initial evaluation.
    S5181Home health respiratory therapy, not otherwise specified, per diem.
    S5497Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S5517Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting.
    S5518Home infusion therapy, all supplies necessary for catheter repair.
    1–10 of 28
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    Applicable CodesHCPCS
    S9325Home infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9326Home infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9327Home infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9328Home infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9329Home infusion therapy; administrative services, care coordination, and all necessary supplies and equipment, per diem.
    S9330Home infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9331Home infusion therapy, intermittent chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9335Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9336Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    S9338Home infusion therapy, immunotherapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.
    1–10 of 34
    1/4
    Applicable CodesHCPCS
    S9367Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
    S9368Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
    S9370Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem.
    S9372Home therapy, intermittent anticoagulant injection therapy, e.g., Heparin; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem. Do not use this code for flushing of infusion devices with Heparin to maintain patency.
    S9373Home infusion therapy, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem. Do not use with hydration therapy codes S9374-S9377 using daily volume scales.
    S9374Home infusion therapy, hydration therapy; 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem.
    S9375Home infusion therapy, hydration therapy; more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem.
    S9376Home infusion therapy, hydration therapy; more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem.
    S9377Home infusion therapy, hydration therapy; more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies, drugs and nursing visits coded separately, per diem.
    S9379Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, drugs and nursing visits coded separately, per diem.
    1–10 of 28
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    Typical Daily Duration
    Care patternIntermittent and part time
    Typical daily durationLess than four hours per day
    ExceptionMore care may be allowed when the need is finite and predictable

    Documentation and Denial Risks

    Documentation Required

    Practitioner Order Required

    Document that the requested services were ordered and directed by the treating practitioner or specialist responsible for the member’s care.

    • The ordering professional must be an MD, DO, PA, or NP.
    Documentation Required

    Skilled Home-Care Rationale

    Document the specific medical outcome sought, the clinical rationale for home care, and that care will be delivered or supervised by a licensed professional to achieve that outcome.

    • Identify the responsible licensed professional and the services to be delivered or supervised.
    • Explain why the requested services are needed in the member’s place of residence.
    Documentation Required

    Clinical Skill Requirement

    Policy Background

    This Tennessee policy addresses home health and skilled care services delivered in the member’s home or another qualifying non-institutionalized setting. Services within its scope include skilled nursing, therapy and rehabilitation, aide services, social work, infusion, nutrition, respiratory care, wound care, and related home-based services. Medical necessity requirements depend on the member’s program: TennCare Medicaid providers should apply the applicable Tennessee rules, while Tennessee CoverKids providers should use the applicable InterQual Home Care criteria.

    Key Definitions

    Place of Residence for Home Health Services
    Qualifying settingAny non-institutionalized setting where normal life activities take place
    Excluded settingsA setting where Medicaid payment is or could be made for inpatient services that include room and board
    Examples of excluded settingsHospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities, subject to limited exceptions
    Home Health Care
    DurationShort-term services
    AuthorizationPrescribed by a treating practitioner or specialist, including an MD, DO, PA, or NP
    Policy Summary
    PayerUnitedHealthcare
    PolicyHome Health, Skilled, and Custodial Care Services (for Tennessee Only)
    Policy CodePolicy CS137TN1.K
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument the treating practitioner's or specialist's order and direction for the requested services.
    SourceLink
    On This Page
    Coverage CriteriaApplicable Codes and Coding ParametersDocumentation and Denial RisksPolicy BackgroundKey Definitions
  1. Intermittent and part time, typically provided for less than four hours per day.

    An exception to the intermittent-care requirement may be made in certain circumstances when the need for more care is finite and predictable.

  2. Skilled care in the member's place of residence

    • The skilled care consists of skilled nursing, skilled rehabilitation, or skilled teaching.
    • The care requires clinical training in order to be delivered safely and effectively.

    • Skilled rehabilitation may include:

      • Physical therapy.
      • Occupational therapy.
      • Speech therapy.

    • Eligible therapy benefit placement

      • Physical, occupational, or speech therapy received in the home from a home health agency is covered under the home health care benefit.
      • Physical, occupational, or speech therapy received in the home from an independent physical, occupational, or speech therapist who is not affiliated with a home health agency is covered under the rehabilitation services-outpatient therapy benefit.
    • Medical supplies and medications used in conjunction with a home health care visit are covered as part of that visit.

      Examples include catheters, irrigation devices, surgical dressings, and syringes; this list is not exhaustive.

    3. Document that the requested care requires clinical training to be delivered safely and effectively. Covered skilled care in the member’s residence includes skilled nursing, skilled rehabilitation, and skilled teaching.

    • Skilled rehabilitation includes physical, occupational, and speech therapy.
    • Home therapy from a home health agency is covered under the home health care benefit; therapy from an independent therapist is covered under the outpatient rehabilitation services benefit.
    • Medical supplies and medications used with a home health visit, such as catheters, irrigation devices, surgical dressings, and syringes, are covered as part of that visit when otherwise eligible.
    Documentation Required

    Frequency and Duration

    Document that services are intermittent and part-time, typically provided for less than four hours per day, and specify the planned frequency and duration.

    • If more care is needed, document that the exception is finite and predictable and explain its expected duration.
    Billing Rule

    Code Listing Does Not Guarantee Coverage

    Listed procedure and diagnosis codes are provided for reference only and may not be all-inclusive. Inclusion of a code does not establish that a service is covered or non-covered, create a right to reimbursement, or guarantee claim payment; benefit coverage is determined by applicable federal, state, contractual, and legal requirements, and other policies or guidelines may apply.

    • Do not rely on code listing alone to determine coverage or payment.
    Denial Risk

    Custodial or Convenience Care

    Services may be denied when they are custodial in nature or are provided primarily for the comfort and convenience of the member or the member’s family.

    • Document the skilled medical purpose of the requested services rather than routine personal, maintenance, or convenience needs.
    Denial Risk

    Not a Substitute for Facility-Based Skilled Care

    Services may be denied when they are not provided in the home in lieu of skilled care that would otherwise be delivered in another setting, including a nursing facility, acute inpatient rehabilitation facility, or hospital.

    • Document why home-based care is appropriate in place of facility-based skilled care.
    Denial Risk

    Inappropriate or Higher-Cost Alternative

    Services may be denied when they are not clinically appropriate or when a less costly alternative health service is available and appropriate.

    • Document the clinical appropriateness of home care and why the requested service is no more costly than an appropriate alternative.
    Denial Risk

    Excessive or Unpredictable Duration

    Services may be denied when they are provided on a non-intermittent or excessive basis, or when the duration of increased care is not predictable.

    • Support the requested schedule with a defined frequency and duration.
    • For an intermittent-care exception, identify the finite need and predictable end point.
    Denial Risk

    No Skilled-Care Requirement

    Skilled care may be denied when the requested services do not require clinical training to be delivered safely and effectively.

    • Demonstrate the clinical skills required for the requested nursing, rehabilitation, or teaching services.
    • Routine or non-skilled tasks that can be performed safely without clinical training do not satisfy the skilled-care requirement.
    Delivery location
    Delivered in the health plan member's residence
    PurposeHelps the member recover after illness, injury, hospitalization, or surgery, or manage a chronic condition
    Functional goalRestores or maintains the member's maximal level of function and health
    Care-setting goalProvided in lieu of services in an outpatient, acute, or sub-acute health care setting
    Skilled Care
    Nature of serviceMedically necessary services
    LocationProvided in the member's place of residence
    ProvidersDelivered by licensed health care professionals
    ExamplesMedical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, and occupational therapy
    Custodial Care
    Nature of serviceNonmedical services
    Personal assistanceAssistance with personal care activities of daily living
    Household assistanceHousekeeping, cooking, or laundry
    Medication supervisionSupervision of self-administered medication
    Qualified caregiverCare that can reasonably and safely be provided by nonlicensed caregivers
    Skilled Care Categories
    Skilled nursingA skilled care category identified by the policy
    Skilled rehabilitationIncludes physical therapy, occupational therapy, and speech therapy
    Skilled teachingA skilled care category identified by the policy
    Clinical training requirementThe care must require clinical training to be delivered safely and effectively