All underlined words contained in this document should serve as hyperlinks to the appropriate internet resource. Email dmhfmedicalpolicy@utah.gov if any of the links do not function properly noting the specific link that is not working and the page number where the link is found.
For general information regarding Utah Medicaid, refer to Section I: General Information, Chapter 1, General Information.
Medicaid covers skilled nursing, physical therapy, and home health aides for categorically and medically needy members.
Occupational therapy, speech-language pathology and audiology, and private duty nursing services are covered for pregnant members and those eligible for the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program when medically necessary.
Home health services are a benefit of the Utah Medicaid Program as described in this section. Home health services are medically necessary, part-time, intermittent health care services provided to eligible members in settings defined by 42 CFR Part 440.70 when they are medically necessary, cost-effective, and consistent with the member’s medical need.
Home health services must be based on a physician’s order and a documented plan of care. The home health care provided must require the skills of technical or professional personnel such as a registered nurse (RN), licensed practical nurse (LPN), trained and certified home health aide, physical therapist, occupational therapist, or speech pathologist.
The goals of home health care are to:
The home health agency should effectively coordinate services to meet the members medical needs in their place of residence. When a skilled home health nurse is authorized to provide a service, other medically necessary services should be provided at the same time. Additional visits will not be authorized for services which could be provided during other visits.
Home health service must be supervised by a registered nurse employed by an approved, Medicare-Certified Home Health Agency.
Information specific to ACOs can be found in Section I: General Information, Chapter 2, Health Plans.
Refer to Section I: General Information Chapter 1-7, Fee-for-Service and Managed Care for information regarding Accountable Care Organizations (ACOs) and how to verify if a Medicaid member is enrolled in an ACO.
To enroll as a Medicaid Home Health Provider refer to Section I: General Information Chapter 3, Provider Participation and Requirements.
Refer to Section I: General Information , Chapter 4, Record Keeping.
Refer to Section I: General Information , Chapter 5, Provider Sanctions.
It is the responsibility of the provider to verify the member's eligibility prior to every rendered service. For additional information regarding member eligibility refer to Section I: General Information Chapter 6, Member Eligibility.
For information on member responsibilities including establishing eligibility and co-payment requirements refer to Section I: General Information , Chapter 7, Member Responsibilities.
Definitions of terms used in other Medicaid programs are available in Section I: General Information of the Utah Medicaid Provider Manual. Definitions specific to the content of this manual are provided below.
Clinical Note: A notation of contact with a member written and dated by a member of the health team. It describes signs and symptoms, treatment and drugs administered and the member’s reaction, and any changes in physical, emotional condition, or other health information.
Home Health Agency Visit: A personal contact in the member’s place of residence for providing a covered service.
Home Health Agency or Home Care Agency: A public agency or private organization licensed by the Department as a home health agency under the authority of Utah Code Title 26, Chapter 21, and in accordance with Utah Administrative Code R432-700. a home health agency is primarily engaged in providing skilled nursing service and other therapeutic services.
Home Health Aide (HHA) or Certified Nursing Assistant (CNA): Services provided by a person selected and trained to assist with routine care not requiring specialized nursing skill and closely supervised by a registered nurse. Home health aide services must be provided by a Medicare-certified and Utah State licensed Home Health Agency through an established plan of care.
Home Health Assessment Visit: Made by a registered nurse initially or at recertification to assess the member’s overall condition; to determine the adaptability of the member’s place of residence to the provision of health care and the capability of the member to participate in his own care; and to identify family support systems or individuals willing to assume responsibility for care when the member is unable to do so.
The outcome of the assessment visit is a documented plan of care based on the physician's written orders and the registered nurse’s assessment.
Plan of Care: A written plan developed cooperatively by the home health agency staff and the member’s attending physician. The plan is designed for the agency to adequately meet the specific needs of the member in the member’s place of residence, be based on orders written by the physician, and be signed by the physician. The approved plan must be incorporated in the agency’s permanent record for the beneficiary.
Private Duty Nursing (PDN): Private duty nursing is an optional program which is covered within the Home Health Program for members who meet specified criteria and require more than four continuous hours of skilled nursing care per day.
Private Duty Nursing Acuity Grid: A form developed by the State of Utah to assist the assessing RN to determine the acuity level of the beneficiary. The form is available at General PA Forms.
Progress Note: Progress note means a written notation, dated and signed by a member of the health team, which summarizes facts about care furnished and the member’s response during a given period.
Skilled Nursing: Nursing services are specifically skilled services used in the treatment of an acute illness or injury or exacerbation of a chronic illness.
Summary Report: Summary report means the compilation of the pertinent factors of a member’s clinical notes and progress notes from the previous certification period that is submitted to the member’s physician.
Supervision or Supervisory Visit: Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity.
Supportive Maintenance Home Health: A level of hands-on service which requires minimal assistance, observation, teaching or follow-up essential to health care.
Home health services are covered only when provided to a member who is under the care of a physician. Home health services must comply with Utah Administrative Code R414-1-30. The physician writes the orders on which an assessment is based and plan of care established, certifies the medical necessity for home health services, and provides supervision of cares. Home health care is physician-directed and must be furnished by or under the supervision of a registered nurse.
Home health services require prior authorization except for the initial and 60-day recertification assessments.
Refer to the Coverage and Reimbursement Code Lookup for additional covered services.
Home health services include:
Criteria for each service are described in the remainder of this manual.
Nursing services, as defined in the Utah Nurse Practice Act, are covered when provided on a part-time basis by a home health agency. Part-time or intermittent services are usually services for a few hours a day several times a week. Occasionally, more services may be provided for a limited time when recommended by a physician and included in the approved plan of care. Skilled nursing service is the expert application of nursing theory, standardized procedures and medically delegated techniques by a registered nurse (RN) to meet the needs of a member in his or her residence, using professional judgments to independently solve member care problems.
Highly skilled nursing levels of care occur where the severity of illness and intensity of service are such that the attendance of a family or professional care-giver is necessary on a consistent basis; specialized equipment is required to support activities of daily living; and abilities are severely limited by medical needs, treatment, supportive equipment and the need for physical assistance; and the skill required can only be provided by a licensed RN or LPN.
Teaching is limited to four visits in the first certification period.
The registered nurse makes the initial assessment and recertification visits, regularly reevaluates the member’s nursing needs, initiates the plan of care, makes necessary revisions, provides services requiring substantial and specialized nursing skill, initiates appropriate preventive and rehabilitative nursing procedures, prepares clinical and progress notes, coordinates services, informs the physician and other personnel of changes in the member’s condition and needs, counsels the member and family in meeting nursing and related needs, participates in in-service programs, and supervises and teaches other nursing personnel.
An in-depth physical and psychosocial assessment must be made by a registered nurse initially or at recertification to assess the member’s overall condition, needs, adaptability of the member’s place of residence to the provision of health care, capability of the member to participate in his or her own care, identify family support systems or persons willing to assume responsibility for care when the member is unable, and establish a plan for delivery of care.
The home health agency may conduct an initial assessment visit on the reasonable expectation that a member’s needs can be met adequately in their place of residence. The outcome of the assessment visit is a documented plan of care based on the physician's written orders and the registered nurse’s assessment.
The plan of care is a written plan developed cooperatively by the home health agency staff and the member’s attending physician. The plan must be designed for the agency to adequately meet specific needs of the member in the member’s place of residence, be based on orders written by the physician, and be signed by the physician. The approved plan must be incorporated in the agency’s permanent record for the member.
The plan of care developed in consultation with the agency staff must cover the following:
At least every sixty (60) days, the member must undergo reassessment. The physician must review the new plan of care and recertify the need for continuing home health care. Medicaid must approve an updated plan of care at least every 60 days. A 60-day summary of care from the previous certification period must be included on every care plan after the initial authorized period. Exceptions to this requirement are located in chapter 8-8 IV, Enteral, and Parenteral Therapy Administration.
The average member is served by home health for 60-75 days. As the 60-day time frame nears, the home health agency should determine the need for continued care and complete a new prior authorization request. Include all information and documentation as was initially required. This reassessment can take place no more than five days prior to, or two days after, the previous certification period expires.
Home health care services must be administered by agency staff only as ordered by a physician and approved in the plan of care. All changes shall be made in writing and signed by the physician or by a registered nurse on the staff of the agency receiving the physician's oral order. All oral orders must be subsequently documented in writing on or before the next plan review. All changes in orders for legend drugs and narcotics must be signed by the physician.
If the member does not require home health care for the entire 60-day period, service should be discontinued as appropriate.
Physical Therapy services are covered through home health when the setting is the most appropriate and cost effective. Physical therapy services must be medically necessary and essential to improve the functional ability of a member with a temporary or permanent disability associated with accidents, injury, illness, birth defects, or prematurity. The goal of physical therapy in the home is to improve the ability of the beneficiary, through the rehabilitative process, to function at a maximum level.
Physical therapy must be provided under physician orders, in accordance with an established plan of care, and provided by a licensed, qualified physical therapist or physical therapy assistant employed directly by or under contract with a home health agency.
There must be an expectation that with treatment, the member’s medical condition will improve in a predictable period of time. Physical therapy delivery by a home health agency is not an option for the convenience of physician, family, or therapist. Outpatient service must be considered for any continuing service beyond the initial intervention.
Before physical therapy is provided by the home health agency, prior authorization must be requested with submission of an initial assessment that includes, but is not limited to:
The plan of care and progress toward goals must be reviewed by the nurse reviewer every 60 days and reviewed and recertified by the attending physician every 6 months. Requests for continued service will be evaluated by consultants and nursing staff on a case-by-case basis. A new plan of care must be submitted with a prior authorization request, and must include the following information:
Occupational Therapy services are covered through home health when the setting is the most appropriate and cost effective. Occupational therapy is a benefit available for pregnant members and those eligible for the EPSDT program.
Occupational therapy services must be medically necessary and essential to treat problems associated with accidents, injury, illness, birth defects or prematurity. Therapy should maximize the developmental or functional needs of member performance to include any or all of the following:
Evaluation and treatment services are available to correct or ameliorate physical and/or emotional deficits.
Occupational therapy must be provided under physician orders, in accordance with an established plan of care, and provided by a licensed, qualified occupational therapist or certified occupational therapy assistant employed directly by or under contract with the home health agency.
There must be an expectation that with treatment, the member’s medical condition will improve in a predictable period of time. Occupational therapy delivery by a home health agency is not an option for convenience of physician, family or therapist. Outpatient service must be considered for any continuing service beyond the initial intervention.
Typical activities related to occupational therapy are:
Before therapy services are provided by the home health agency, prior authorization must be requested with submission of an initial assessment that includes, but is not limited to:
The plan of care and progress toward goals must be reviewed by the nurse reviewer every 60 days and reviewed and recertified by the attending physician every 6 months. Requests for continued service will be evaluated by consultants and nursing staff on a case-by-case basis. A new plan of care must be submitted with a prior authorization request, and must include the following information:
Occupational Therapy services are non-covered for the following:
Speech-language services are covered under home health when the setting is the most appropriate and cost effective. Speech-language pathology and audiology services are available to eligible pregnant and EPSDT members when determined to be medically necessary.
Speech-language services must be essential to treat problems associated with birth defects, prematurity, illness, accidents or injury. All services must be provided under physician orders, in accordance with a plan of care, and provided by a licensed, qualified speech-language therapist employed directly by or on contract to a home health agency. There must be an expectation that with treatment, the member’s medical condition will improve in a predictable period of time. Speech-language services delivery by a home health agency are not an option for the convenience of physician, family, or therapist. Outpatient service must be considered for any continuing service beyond the initial intervention.
Before services are provided, the home health agency must request prior authorization and submit an initial assessment that includes, but is not limited to:
The plan of care and progress toward goals must be reviewed by the nurse reviewer every 60 days and reviewed and recertified by the attending physician every 6 months. Requests for continued service will be evaluated by consultants and nursing staff on a case-by-case basis. A new plan of care must be submitted with a prior authorization request, and must include the following information:
Speech-language services are non-covered for the following:
Medical supplies for home health services are included in the coverage of the initial visit related to the start of care and are not separately reportable.
Medical supplies included in the plan of care are subject to coverage and prior authorization requirements of the Medical Supplies and Durable Medical Equipment services program.
Refer to the Medical Supplies and Durable Medical Equipment Provider Manual and the Coverage and Reimbursement Code Lookup for additional information about this program.
The administration of enteral, parenteral, and IV therapy is covered as a home health service either in conjunction with skilled or supportive maintenance care or as the only service provided. Refer to the Pharmacy Services and Medical Supplies and Durable Medical Equipment Provider Manuals for coverage policy regarding these services.
Long-term IV access, such as PICC or central line placement, is required when a member requires administration of IV antibiotics for a 7-10 day period or parental nutrition therapy. IV dressing changes are covered once every 7-day period. Members with documented risk of infection or that are pregnant are excluded from this requirement and can have a visit every three days for peripheral line maintenance when medically appropriate.
Skilled nursing is appropriate for IV placement, demonstration of IV medication delivery; blood draws associated with infusion therapy, or teaching. Medical necessity of administration in the home health setting and the member’s condition and must be established based on the appropriateness diagnosis. The plan of care for infusion therapy must include:
The supportive maintenance level of service includes skilled nursing and home health aides. These services are available to the member with nursing care needs that have stabilized to the point that there are few significant changes occurring in the plan of care. The member demonstrates limitations or significant disability that requires assistance with activities of daily living (ADL) and could be totally bed bound or subject to nursing facility admission without the assistance. Care and service needs are based on physician orders and an approved plan of care, with review and recertification completed by the home health agency and the physician, every 60 days. Teaching, assessment, observation, and monitoring by a skilled nurse must be accompanied by hands on care.
Supportive maintenance levels of care occur where the member demonstrates chronic limitations or significant disability requiring assistance with ADLs or specialized equipment which may require ongoing observation, teaching, and hands on follow-up care. Care needs should be relatively stable, supportive in nature, and long-term. The member is typically capable of leaving their place of residence to attend school, sheltered workshops, work or to receive other medically necessary services. Assistance may be needed multiple times per day.
Examples of members with diagnosis(es) requiring this level of care include, but are not limited to:
Home health aide related services are covered when medically necessary and part of an ongoing plan of care. The members severity of illness and required intensity of service must be such that the skills of a home health aide meets their needs on a consistent basis, at an appropriate skill level.
Home health aide visits can occur daily one or more times per day with coverage determinations based on a member’s medical needs.
A member may be eligible for the long-term capitated home health program when documented, diagnosed medical conditions require extensive services or substantial physical assistance with activities of daily living but little skilled care.
Capitated home health care provides service for members with paraplegia and quadriplegia who require little skilled care and need long term maintenance with activities of daily living, along with other services, usually twice a day. Once a member is approved for capitated home health care, the reimbursement is based on the cost of nursing facility care per day. The home health agency provides the required care to meet the member’s needs without billing for each service or visit.
Criteria considered by Medicaid Prior Authorization staff include:
Note: As with any other plan of care, any change in the member’s condition or care needs requires immediate evaluation and reconsideration of the service authorization.
The capitated service represents a daily rate. No other home health services can be provided or billed when the member is receiving service under the capitated program.
PDN service is an optional program for the purpose of preventing prolonged institutionalization of a member. As an optional program, PDN is a non-covered program for Medicaid members except EPSDT eligible members.
In certain cases, if agency staff determine that the proposed PDN services are both medically appropriate and more cost effective than alternative services, the agency may exceed the limitation of PDN coverage beyond EPSDT eligible members.
PDN services are covered when criteria are met and determined to be medically necessary. PDN is only available if a parent, guardian, or primary care giver is able to perform the medical skills necessary to ensure quality of care and a safe environment for the periods of time when PDN service is not provided.
PDN services are for medically necessary skilled nursing needs of the member that meet the following criteria:
PDN is not covered for:
Coverage of PDN requires:
The following documentation must be submitted for consideration or reconsideration for PDN services. All requested forms and documentation must be submitted together.
The PDN Acuity Grid is used to determine medical necessity and to qualify and quantify the number of PDN hours that a member may receive.
The PDN Acuity Grid:
If a member is discharged from the hospital, the PDN Acuity Grid is submitted based on an estimate of the care needed, the discharge orders, or other documents from the hospital.
After the initial care period, ongoing care needs are determined by documentation from the previous 60 days of care.
If during a recertification period or after transition from hospital to the home health setting, continued PDN care is not substantiated, it is expected that the member will be given time to seek alternative care from community resources.
| Score | Hours of care per day of shift care (up to) |
|---|---|
|
21-35 |
9 |
|
36-45 |
11 |
|
46-51 |
13 |
|
56+ |
15 |
If 20 points or less:
Active weaning occurs as follows, when indicated by PDN grid scores:
An increased number of hours of PDN services may be authorized when acute exacerbations of illness require a temporary increase in skilled care. Additional documentation may be requested to support the request for increased hours. The member may receive up to 20-24 hours of PDN care daily, if authorized, only under the following circumstances:
The banking, saving, or accumulation of unused, authorized hours to be used later for the convenience of the family or agency is not permitted.
Home health agencies may adjust or combine PDN hours within a 7-day period based on the needs of the family. Combing PDN hours should not be a common practice and it is not permissible to combine PDN hours because the agency could not staff a shift.
The following provides billing information for PDN services:
Medicaid does not cover home health services in the following situations:
The following limitations apply to home health services:
Prior authorization (PA) may be required for certain services. Failure to obtain prior authorization may result in payment denial by Medicaid. Providers must determine if prior authorization is necessary and obtain authorization before providing services. Exceptions may be made, with appropriate documentation, if the service provided is emergent or the member is retro-eligible for the dates of service requested.
Further prior authorization information is provided in the provider manual, Section I: General Information. Code specific coverage and prior authorization requirements are provided on the Coverage and Reimbursement Code Lookup.
To request prior authorization the home health agency must submit the physician’s written order requesting care, the plan of care resulting from those orders, and a Request for Prior Authorization form for all home health services beyond the initial visit, including therapies. Approval must be received before additional services are given. The level of service, skilled, supportive, or maintenance, is established and approved based on the prior authorization request.
Prior authorization is not required for the initial comprehensive nursing assessment or the nursing assessment required at recertification. A recertification assessment every 60 days is a federal requirement with reimbursement limited to one every 60 days. All other home health services require prior authorization. Recertification requests must be submitted every 60 days. The member cannot be discharged if the deadline for re-certification has been missed. Certification periods must be consecutive.
Prior authorization is required for a physical, occupational, or speech therapy assessment. The assessment determines if the member is able to receive necessary services in the outpatient setting. Therapy visits are limited to the most appropriate, cost-effective place of service. The home health setting cannot be chosen for the convenience of the therapist or family.
Prior authorizations for home health services are provider specific. This means that only the agency that applied for and received the prior authorization may use the authorization number. If another agency assumes responsibility for serving the beneficiary, that agency must apply for and receive a separate prior authorization.
The location of the member must be documented in the request for home health services (i.e. own home, group home, assisted living center).
Retro authorization must be requested with a PA request form, physician order for care, and nursing documentation of visit for all PRN nursing visits.
When the nursing assessment indicates a Medicaid member may qualify for home health services, fax the Request for Prior Authorization form and all required documentation within 10 calendar days of the nursing assessment. Documentation must be submitted at the time of the request, or the request will be returned. Prior authorization forms can be found on the Utah Medicaid website Forms section.
For general information related to billing Medicaid refer to chapter 11 Billing Medicaid of the Section I: General Information provider manual for additional billing instructions.
Medicaid provides enhancements to the home health reimbursement rate when travel distances to provide service are extensive. The enhancement is available only in rural counties where round-trip travel distances from the care giver’s base of operations are in excess of 50 miles.
Rural counties are defined as counties other than Weber, Davis, Salt Lake, and Utah. The member must reside in the same or an adjacent rural county as the provider.
An enhancement factor is applied to home health services rendered for residents living in San Juan or Grand County. This enhancement is irrespective of the distances traveled and is in lieu of the rural area exceptions provided for other rural counties.
See chapter 12 Coding for guidance related to claims submitted for these services.
Home health services requiring minimal time and performed for multiple persons in the same location shall be billed with the appropriate modifier as noted below.
| Number of members served | Applied Modifier |
|---|---|
|
2 |
UN |
|
3 |
UP |
|
4 |
UQ |
|
5 |
UR |
|
6+ |
US |
Divide the total number of units by the total number of members served.
The resulting number of units is billed to each member along with the appropriate modifier to indicate the service was shared. If the units do not divide among the members served into whole numbers, then allocate and bill the remainder units among the members until used.
Example: 4 members received a total of 11 units is calculated and billed as follows:
11/4 = 2.75
Member 1 = 3
Member 2 = 3
Member 3 = 3
Member 4 = 2
This policy is effective as of January 1, 2023.
In accordance with Utah Administrative Code R414-522 and section 12006 of the 21st Century CURES Act, providers of Home Health must comply with Electronic Visit Verification (EVV) requirements. Providers may select the system of their choosing, provided it captures the following data elements and is compliant with the standards set in the Health Insurance Portability Accountability Act (Utah Medicaid Provider Manual Home Health Services, Updated October 2019, Page 20 of 21, Section 2).
EVV systems must collect the minimum information:
Additional information, including technical specifications for file creation/submission can be found at https://medicaid.utah.gov/evv.
To receive the rural home health travel enhancement, file the claim using an applicable, approved service code with a modifier “TN”.
Modifier TN is used for rural counties other than San Juan and Grand County members.
See Chapter 11 Billing Medicaid for guidance related to the conditions required for enhancements to the home health reimbursement rate.
An enhancement factor is applied to home health services rendered for residents living in San Juan or Grand County. This enhancement is irrespective of the distances traveled and is in lieu of the rural area exceptions provided for other rural counties.
To receive the rural home health travel enhancement, file the claim using an applicable approved service code with the appropriate modifier.
| Modifier | Recipients | Zone |
|---|---|---|
|
UA |
|
1 |
|
UB |
|
2 |
|
TN |
|
NA |
The following table is designed to provide hyperlinks to relevant documents, forms, and information to be used in conjunction with this provider manual.
| For information regarding: | |
|---|---|
|
Administrative Rules |
Utah Administrative Code Table of Contents Utah Administrative Code, Title R414-1, Utah Medicaid Program Utah Administrative Code, Title R414-14, Home Health Services Utah Administrative Code, Title R414-40, Private Duty Nursing Service |
|
General information including: Billing Fee for Service and Managed Care Member Eligibility Prior Authorization Provider Participation |
Section I: General Information Managed Care: Accountable Care Organizations Utah Medicaid Prior Authorization Administrative Rules Eligibility Requirements. R414-302. Medicaid General Provisions. R414-301. |
|
Information including policy and rule updates: Medicaid Information Bulletins Medicaid Provider Manuals Utah State Bulletin (Issued on the 1st and 15th of each month) |
|
|
Medicaid forms including: PA Request Private Duty Nursing
|
|
|
Medical Supplies and DME |
Medical Supplies And Durable Medical Equipment Provider Manual Medical Supplies, Durable Medical Equipment, and Prosthetic Devices. R414-70. |
|
Modifiers |
|
|
Patient (Member) Eligibility Lookup Tool |
|
|
Prior Authorization |
|
|
Provider Portal Access |
|
|
Provider Training |
|
|
References including: Social Security Act Code of Federal Regulations Utah Code |
|
The following linked forms and attachments can also be found on the Provider Form Directory of Utah Department of Health and Human Services Medicaid website.
|
Forms and Attachments |
|---|
|
Home Health and Personal Care Prior Authorization Request Form |
Updated September 2022