Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2024 POLICY LAST REVIEWED: 08|02|2023 OVERVIEW Home health care covers a wide range of services. Home Health care may include physical, speech and occupational therapy; in addition, it may involve skilled nursing or assistance with daily needs and monitoring medications.
This policy is NOT applicable to hospice services in the home. PRIOR AUTHORIZATION Not applicable MEDICAL CRITERIA Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Home health care services are covered.
Covered services include skilled care (i.e., care that requires the expertise of a skilled professional). Skilled care services may include: • Nursing servicesSkilled nursing services alone are not to exceed a total of 8 hours per day as it is considered private duty nursing and not home care. Please refer to Private Duty Nursing policy. • Physical Therapy (PT) and/or Occupational Therapy (OT) PT and OT services may include services provided by a Physical Therapy Assistant (PTA) or Certified Occupational Therapy Assistant (COTA) working under supervision of a licensed Physical or Occupational therapist (as appropriate) • Speech Language Pathology (SLP) services • Medical Social Services` • Home Health Aide (directly related to the skilled plan of care) Home health aide services are covered for up to 2 hours per day. These services typically are not required for more than 2 hours per day. The duties of a home health aide are to provide services needed to maintain the patient's health or to facilitate treatment of the patient's illness or injury. Services that are over the 2 hour per day limit will be retrospectively reviewed and if these services are considered custodial care as defined by Medicare (see below) BCBSRI will consider them excluded from coverage Non-covered services: • Custodial care, homemaking, or maintenance therapy. Custodial care are considered services used for the purpose of meeting nonmedical personal care to help with activities of daily living (e.g., bathing, dressing, food preparation, eating, getting into or out of bed or chair, and using the bathroom) including homemaking, companionship, or maintenance therapy and are a contract exclusion. • Services of a personal care attendant. • Charges for private duty nursing. See policy on Private Duty Nursing. Payment Policy | Home Health Services - Skilled

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable Home Health Care coverage. The home health care provider is responsible for verifying a member’s eligibility and benefit coverage.

BACKGROUND Home health services are typically utilized for the following situations when a member is: 1) Considered homebound as defined by the following:
a. Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence OR
b. Have a condition such that leaving his or her home is medically contraindicated.
c. And both of the following conditions: i. There must exist a normal inability to leave home; AND
ii. Leaving home must require a considerable and taxing effort. 2) Under the care of a provider (MD, DO or Midlevel Practitioner). 3) Receiving services under a plan of care established and periodically (every 60 days) reviewed by a provider 4) In need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. 5) Under care that is inherently complex, which means that they can be performed safely and/or effectively only by or under the general supervision of a skilled therapist or nurse 6) Under care that is consistent with the nature and severity of the illness or injury and the patient’s particular medical needs, which include services that are reasonable in amount, frequency, and duration
7) Under care that is considered specific, safe, and effective treatment for the member’s condition under standards of medical practice

Definitions Home Confined
A patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated.

An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. ...If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to:
• Attendance at adult day centers to receive medical care; • Ongoing receipt of outpatient kidney dialysis; or
• The receipt of outpatient chemotherapy or radiation therapy.

Place of Residence A patient's residence is wherever he or she makes his or her home. This may be their own dwelling, an apartment, a relative's home, a home for the aged, or an institution such as an assisted living facility, group home or personal care home.

Part time or intermittent
Part-time or intermittent home health aide services or skilled nursing services is defined as "The term "part- time or intermittent services" means skilled nursing and home health aide services furnished any number

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours each week).

Documentation Requirements The documentation of services must be maintained in the member’s medical documentation and include the following:
• Initial evaluation results, evidence of homebound status and individualized member goals and plan of care • Number of visits needed and duration • For each discipline, goals that were met and not met • Progress made toward any unmet goals • Any barriers identified that will impact the member’s ability to meet the unmet goals • The plan to address those barriers, including follow-up with the ordering provider • Anticipated number of visits needed to meet goals

CODING The following code(s) are covered:
S9122 Home health aide or certified nurse assistant, providing care in the home S9123 Nursing care, in the home; by registered nurse S9124 Nursing care, in the home; by licensed practical nurse* S9127 Social work visit, in the home, per diem S9128 Speech therapy, in the home, per diem S9129 Occupational therapy, in the home, per diem S9131 Physical therapy; in the home, per diem S9470 Nutritional counseling, dietitian visit

*This code is not applicable for home health care providers that are participating with Blue Cross & Blue Shield of Rhode Island. BCBSRI Par local Home Health Care providers should follow coding guidelines in their contract and use S9123 for RN and LPN services.

The following code(s) are not applicable for home health care providers that are participating with Blue Cross & Blue Shield of Rhode Island (BCBSRI). Codes will deny as use alternate if filed by a local BCBSRI provider. These may be filed by out of state providers and are covered: G0151 Services of Physical Therapist in home health setting, each 15 minutes G0152 Services of Occupational Therapist in home health setting, each 15 minutes G0153 Services of Speech and Language Pathologist in home health setting, each 15 minutes G0156 Services of Home Health Aide in home setting, each 15 minutes G0157 Services performed by a qualified physical therapy assistant in the home health setting, each 15
minutes G0158 Services performed by a qualified occupational therapy assistant in the home health setting, each 15
minutes 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 license practical nurse (LPN) in the home health or hospice
setting, each 15 minutes

RELATED POLICIES Private Duty Nursing
Advanced Practice Providers

PUBLISHED Provider Update, April 2023, November 2023

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, May 2022 Provider Update, May 2021 Provider Update, May 2020 Provider Update, October 2018

REFERENCES:

1. Centers for Medicare and Medicaid Services: Your Medicare Benefits. http://www.medicare.gov
2. Medicare Benefit Policy Manual: Chapter 7 - Home Health Service, https://www.cms.gov/manuals/Downloads/bp102c07.pdf
3. Medicare Claims Processing Manual: Chapter 10 - Home Health Agency Billing. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c10.pdf
4. Federal Register 42 CFR 424.22, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part- 424/subpart-B/section-424.22

5. BCBSRI-Subscriber Agreement HMC2C 2011: Section 3.15, Home Health Care.

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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