Home Health Care Services

Home health care is a wide array of health care and support services provided to a member in their home environment to help treat an illness or injury. Examples of skilled services provided in the home include skilled nursing, physical therapy, occupational therapy, and speech-language pathology services. Qualified home health aide services in conjunction with a skilled service, may also be a part of a skilled home care program that provides personal care assistance to a member in their home.

Note: The home setting may be any place the Member has established his/her place of residence for the time period when home care services are being provided.

Definitions

Skilled Services

• Services which require clinical training and must be provided or supervised by a licensed health care professional (e.g., registered nurse; licensed physical, speech, occupational therapist) in order to be delivered safely and effectively and to obtain a specified medical outcome.

Custodial Services

• Services that are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function, as opposed to improving that function.
• Services that do not require clinical training or supervision by licensed medical professionals in order to be delivered safely and effectively.

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Homebound

In order to be considered homebound, the Member's condition should be such that there exists the inability to leave the home, or consequently leaving the home would require a considerable and taxing effort, or the member has a condition such that leaving home is medically contraindicated. If the Member leaves the home, he or she may still be considered homebound if the absences are infrequent and for short periods of time, or are for health care treatments.

Authorization

The plan uses InterQual® Home Care criteria to determine medical necessity and to authorize home care services after the initial evaluation visit.

Clinical Guideline Coverage Criteria

The plan may authorize coverage of intermittent home health care services when they are:

1. Provided under a plan of care established by and periodically reviewed by a physician
2. Skilled services (see definition above)
3. Medically necessary and reasonable based on the Member's condition and accepted standards of clinical practice
4. An integral part of treatment of the Member's medical condition and associated symptoms
5. Provided to Members who are homebound (see definition above)

Note: The initial skilled nursing (SN), and/or physical therapy (PT) home care assessment/evaluation visit does not require prior authorization. Speech therapy, occupational therapy and/or social worker visit will require prior authorization for the initial evaluation when provided independently and not in conjunction with physical therapy or skilled nursing visits. The plan uses InterQual® criteria to determine medical necessity and to authorize home care services after the initial evaluation visit. Providers requesting authorization after the initial evaluation visit must submit a thoroughly completed Universal Health Plan/Home Health Authorization Form (UHHA) along with evidence of homebound status to the appropriate fax number listed above within 2 days of the start of care.

To review authorization requirements, please consult the applicable Provider Manual for Tufts Health Plan Commercial business, Tufts Health Public Plans, or Harvard Pilgrim Health Care. You can also find important reimbursement information in our Payment Policies, which are located on the Harvard Pilgrim Health Care and Tufts Health Plan provider websites.

Limitations

Custodial services (see definition above) • Benefits for home care may vary by plan/group.

Specific Benefit Coverage

Specific benefit coverage should be verified prior to initiating services by logging on to our website or by contacting Provider Services.

Codes

The following code(s) require prior authorization after the initial evaluation (as outlined above):

Table 1: CPT Codes

• CPT® Codes: 99501
• Description: Home Visit- Early Maternity Discharge Visit or Maternal Child and follow-up care (one visit only)

Table 2: HCPCS Codes

• HCPCS Codes: $9127
• Description: Social work visit, in the home, per diem
• HCPCS Codes: $9128
• Description: Speech therapy, in the home, per diem
• HCPCS Codes: $9129
• Description: Occupational therapy, in the home, per diem
• HCPCS Codes: $9131
• Description: Physical therapy, in the home, per diem

Table 3: Revenue Codes

• 0551: Skilled Nursing, visit charge (per visit up to 2 hours)
• 0552: Skilled Nursing, hourly charge (each additional hour after the first two hours)