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HealthPartners

Coverage criteria policies

Home Health Service

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Contracted providers:

Prior authorization is not required for the administration of intravenous (IV) therapy.

Prior authorization is required for some IV medications. Search for the medication specific policy to determine whether prior authorization is required from Pharmacy Administration for the medication.

Prior authorization is required for more than 15 home care visits per discipline per calendar year. This means 15 visits each of skilled nursing (SN), home health aide (HHA), physical therapy (PT), speech therapy (ST), or occupational therapy (OT) received from contracted vendors.

Non-contracted providers:

Prior authorization is required for home health services provided by non-contracted providers, including services provided solely for administration of IV therapy.

All Home Health Service providers:

Prior authorization is required for extended hours of nursing. Extended hours of nursing are from 15 minutes to 24 hours. Continuous hours of care within a 24 hour period are considered 1 visit, and are reimbursed in 15 min increments.

Coverage

Home health services are generally covered subject to the indications listed below, and per your plan documents.

Skilled nursing, home health aide, physical therapy, speech therapy, or occupational therapy services need to be received from a Medicare Certified agency.

Home Intravenous Therapy (IV) therapy providers are not required to be Medicare certified.

Indications that are covered

For coverage of SN, HHA, PT, ST, or OT home health services, all of the following criteria must be met:

  1. The member must be homebound. *
  2. The care must be:
    1. Medically necessary;
    2. Ordered by a medical practitioner and included in the written home care plan.
    3. Skilled care that cannot be performed by non-medical personnel.
    4. Rendered as rehabilitative or terminal care (and not as custodial or respite care).

*Exceptions to the homebound requirement:

Members receiving up to 2 routine postnatal and / or well infant SN visits within 2 weeks of delivery do not need to be homebound.

Members who are only receiving IV therapy.

Note: If more than one type of home health visit occurs in a day, a separate copayment may apply to each service. In addition, coverage may be limited or have specific copay and coinsurance variances. Please contact Member Services for specifics per your plan documents.

For coverage of home IV therapy, all of the following criteria must be met:

  1. The care must be medically necessary and ordered by a medical practitioner.
  2. The services require skilled care and cannot be performed by non-medical personnel.

Indications that are not covered

  1. SN, HHA, PT, ST, and OT services rendered to members who are not homebound, except as above.
  2. Home health services provided as a substitute for a primary caregiver in the home or as a relief (respite) for a primary caregiver.
  3. Services which are considered custodial in nature, including Personal Care Assistant (PCA) services.
  4. Reimbursement to family members or residents in the member's home for any services.
  5. Services rendered at a school or any site other than the member's home.
  6. Services that can be safely and effectively performed by a non-medical person without direct supervision by licensed personnel. For example, routine cares that can be taught to and provided by a non-licensed person such as routine catheter care, simple suctioning, simple wound care, maintenance exercises, or routine foot care.
  7. Skilled nursing visits for IV line care, medication management or set up, or lab draws only.
  8. Social Worker visits.
  9. Duplication of services.

Definitions

Activities of daily living (ADL’s) are everyday activities such as eating, bathing, dressing, toileting, transferring, continence, personal hygiene and mobility necessary to complete these activities.

Custodial Care describes supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel.

Home health services include one or more of the following disciplines: skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy, home health aide, and intravenous therapy (IV).

Homebound describes a member who is unable to leave home without considerable effort due to a medical condition. For example, a member is considered to be homebound, when the member, due to his/her medical condition, is physically unable to go to work, school, or daycare; or is unable to go grocery shopping, run errands or attend outpatient appointments. A member’s inability to drive, or lack of transportation, does not qualify the member for homebound status.

Rehabilitative therapy is therapy provided by a PT, OT or ST as a restorative service, provided for the purpose of obtaining significant functional improvement, within a predictable period of time, toward a patient’s maximum potential ability to perform functional activities of daily living.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The following CPT codes require prior authorization per the Administrative Process above:

Codes

Description

T1002

RN services, up to 15 minutes

S9123

Nursing care, in the home; by registered nurse, per hour

99600

Unlisted home visit service or procedure

G0299

Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes

T1030

Nursing care, in the home, by registered nurse, per diem

T1031

Nursing care, in the home, by licensed practical nurse, per diem

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

S9131

Physical therapy; in the home, per diem

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

S9129

Occupational therapy, in the home, per diem

G0153

Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

S9128

Speech therapy, in the home, per diem

99509

Home visit for assistance with activities of daily living and personal care

G0156

Services of home health/hospice aide in home health or hospice settings, each 15 minutes

T1021

Home health aide or certified nurse assistant, per visit

The following codes do not require prior authorization:

Codes

Description

99601

Home infusion/specialty drug administration, per visit (up to 2 hours)

99602

Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour

S9338

Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment per diem

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 01/01/1994 - Date of origin
  • 10/31/1994 - Effective date
Review date
  • 12/2017
Revision date
  • 12/16/2016

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