QUEST Integration – Home Health Agencies Billing Criteria

Commonly Billed Services : Coding and Claims

For QUEST Integration, Home Health claims must be billed with revenue, HCPCS, and modifier codes to meet MedQUEST Division (MQD) Electronic Visit Verification (EVV) requirements. More information on MQD EVV requirements is available on the MQD – EVV Page.

All QUEST Integration Home Health services require prior authorization.

The Home Health service codes and modifiers payable by HMSA QUEST Integration are listed below.

Electronic Visit Verification

Med-QUEST Division (MQD) is implementing electronic visit verification (EVV) for Home Health Agency, Personal Care Attendant, and Private Duty Nursing services. Read more here.

Benefit Criteria and Limitations

The current Med-QUEST RFP – RFP-MQD-2014-005, Section 40.740.1 Coverage Provisions for Primary and Acute Care Services, requires the following criteria to be met for HHA services to be covered:

1. Home health services are part-time or intermittent care for members who do not require hospital care. This service is provided under the direction of a physician in order to prevent rehospitalization or institutionalization. A participating home health service provider must meet Medicare requirements.

2. Home health visits shall be covered as follows when part of a written plan of care:

   • Daily visits permitted for home health aide and nursing services in the first two weeks of patient care if part of the written plan of care;
   • No more than three visits per week for each service in the third to seventh week of care;
   • No more than one visit per week for each service in the eighth to fifteenth week of care; and
   • No more than one visit every other month for each service from the sixteenth week of care.

   The following is a list, but not an inclusive list, of the services that are included in home health services:

   • Skilled nursing;
   • Home health aides;
   • Medical supplies and durable medical equipment;
   • Therapeutic services such as physical and occupational, therapy; and
   • Audiology and Speech-language pathology.
3. Home Health services shall be prior authorized. For continuation of services, recertification requirements may apply. Please refer to the Home Health Care medical policy for specific precertification requirements. To precertify, please use the HMSA Precertification Request Form [PDF].
4. Home health social worker services are not a plan benefit for QUEST Integration members.

Revision History