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PAP352

Home Healthcare Coverage Provisions


Provider Administrative Policy

Section
Ancillary Provider
Policy Date
January 2008
Status/Date
Revised/October 2009
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Home Healthcare Coverage Provisions

Custodial Care – Care designated principally to assist a member in engaging in the activities of daily living; or services that constitute personal care and does not require the continuing attention of trained medical or paramedical personnel. Custodial care can also include:

  • Services that constitute personal care, such as help in walking and getting in and out of bed, assistance in eating, dressing, bathing, and using the toilet once a member has reached maximum rehab potential or is unable to participate in therapy
  • Preparation of special diets
  • Supervision of medication

Homebound – Confined primarily to the home due to a medical condition. The term connotes that it is “a considerable and taxing effort” for the member to leave home because of a medical condition and not because of inconvenience.

Home Health Care – Delivering physician-directed nursing services to a homebound member in his or her home on an intermittent basis. The general intentions of home healthcare are to transition a homebound member from a hospital setting to a home or avert a hospital stay.

Plan of Treatment – A written plan describing the home healthcare and treatment services and supplies a member must receive. An attending physician must establish and periodically review the written plan.

Primary Care Giver – A person designated to give direct care and emotional support to a member as part of a home health plan of treatment. A primary caregiver may be a spouse, relative or other individual who has personal significance to the member. A primary caregiver must be a volunteer who does not expect or claim any compensation for services provided to the member.

Skilled Nursing – Nursing service that a licensed RN must render or directly supervise to maximize the safety of a member and to achieve the medically desired result that an attending physician orders and/or directs.

Covered Home Health Services

Home health services covered for members include:

Speech Therapy – Corrective treatment of a speech impairment resulting from illness, disease, surgery, accidental injury, congenital anomalies, cognitive deficits or previous therapeutic processes.

Occupational Therapy – Treatment that employs constructive activities designed and adapted for a physically disabled member to help him or her satisfactorily accomplish the ordinary tasks of daily living and tasks required by the member’s particular occupational role.

Physical Therapy – Treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles, or devices to relieve pain, restore maximum function, or prevent disability following disease, illness, accidental injury, or loss of a body part.

Skilled Nursing Care – Nursing service rendered or directly supervised by a licensed RN. This includes the observation and assessment of the total medical needs of the member, including planning, organization and management of a treatment plan involving multiple services where the application of specialized healthcare knowledge is required to attain a desired result and direct nursing services that require specialized training.

Members Eligible for Home Health Services

The member and home health provider meeting  the following criteria for the member to be eligible for home health benefits:

  • A licensed registered nurse (RN), licensed practical nurse (LPN), licensed physical therapist (PT), licensed occupational therapist (OT) or licensed speech therapist (ST) must provide professional nursing services for the homebound member.
  • A member’s physician must order the services and the services must be medically necessary and prior authorized by Blue Cross of Idaho. The services cannot constitute custodial care.
  • A Medicare certified home health provider must provide the services, which are limited to intermittent skilled nursing care and/or therapies.
  • A member’s physician must review the care at least every 30 days.
  • A member cannot receive home health benefits during any period when he or she is receiving hospice-covered services.

Evaluation and Plan of Treatment

Prior authorization is not required for the initial home health evaluation. A home health provider must provide a written plan of treatment approved by a member's physician within 72 hours after an initial evaluation.  The home healthcare provider must provide the level of treatment appropriate to the physician's request to open a home health case (i.e. if physical therapy is the only service requested, the provider must send a physical therapist for an initial evaluation). The plan of treatment must:

  • Identify the member by name
  • Include the member’s Blue Cross of Idaho identification number
  • Identify the primary caregiver(s) by name and describe his or her relationship to the member

In addition to the plan of treatment, a provider must also submit written verification that a member meets the eligibility criteria for home health benefits, to include explanation of the member's homebound status.

Blue Cross of Idaho will deny home health claims that do not have prior approval and the provider agrees not to bill a member for services that do not have prior authorization.

If medical necessity requires treatment beyond a member's original treatment plan, a provider must submit an updated treatment plan at least 5 business days prior to completion of the current treatment plan. Blue Cross of Idaho will deny claims that fail to meet prior authorization requirements and the provider agrees not to bill the member.

A provider must immediately notify Blue Cross of Idaho’s medical management department of any change in a member’s condition or plan of treatment that may affect eligibility for home healthcare benefits. Within 48 hours of notifying the medical management department of any status changes, providers must also provide Blue Cross of Idaho with all medical information necessary to make a medical determination.


Policy History

Date Action Reason
October 2009 Revised Custodial care section updated
August 2008 Revised Language clarification

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