Benefit Criteria - Home Health Agencies

Commonly Billed Services

The matrix below depicts commonly billed services and acceptable code ranges that correspond to HMSA's claims processing requirements for Home Health Agencies (HHA). The matrix represents a range of possible combinations and should not be viewed as comprehensive.

Coding: Home Health Agency

Covered Services

Note: CPT and HCPCS codes are not required when billing for these home health agency services. The revenue codes are specific enough for HMSA to calculate payment.

Incidental Drugs and Supplies

Note: Incidental drugs and supplies are used to deliver the HHA service. These items are included in the all-inclusive rate and are not reimbursed separately.

Benefit Criteria

General

The following criteria must be met for HHA services to be covered:

• Services must be ordered by and included in the plan of care (POC) established by the physician for the member.
• Patient must be homebound
• Services must be reasonable and necessary for the treatment of the member's illness or injury.
• Services must be required on an intermittent basis.

Skilled nursing visits

In addition to the general criteria, skilled nursing visits are covered only if the services, in order to be safe and effective, require the skills of a registered nurse (RN) or licensed practical nurse (LPN) licensed vocational nurse (LVN) under the supervision of an RN.

Skilled therapy visits

In addition to the general criteria, skilled therapy visits are covered only if the complexity of the service requires the general supervision of a skilled therapist in order to be safe and effective. The diagnosis or prognosis should not be the sole factor in deciding whether a skilled therapist is necessary. Occupational therapy is covered only if a skilled nursing, speech or physical therapy service was rendered in the current or prior certification period.

Home health aide visits

In addition to the general criteria, home health aide visits are covered only if the reason for services is to provide hands-on personal care for the member. The physician's order must indicate the frequency of home health aide services.

Note: A skilled nursing or skilled therapy visit must be provided for home health aide coverage to be applied.

Medical social service visits

In addition to the general criteria, medical social service visits are covered only if the services are provided by a qualified medical social worker or social worker assistant under the supervision of a qualified medical social worker. The physician's order must indicate the frequency of the medical social worker's services.

Benefit Limitations

HMSA's private business plans cover up to a maximum of 150 qualified HHA visits per calendar year. If continued HHA services are needed beyond the 150-visit maximum, the physician must recertify every 30 days. The attending physician must certify in writing that the beneficiary meets each of the criteria listed below.

• Member is homebound due to injury or illness.
• Member requires part-time skilled health services.
• Member would require inpatient hospital or skilled nursing facility care if not for home healthcare.

UB-04 Highlights: Sample Claim

See UB-04 Highlights: Sample Claim for Home Health Agencies [PDF] for a sample of the claim explained below.

Explanation of sample claim

Revision History