Is Home Health Care Covered by Highmark Blue Shield
| Medical Policy: | V-21-006 |
| Topic: | Physician Certification and Recertification of Home Health Services |
| Section: | Visits |
| Effective Date: | January 1, 2012 |
| Issue Date: | May 14, 2018 |
| Last Reviewed: | May 2018 |
This policy provides guidelines for certification and recertification by physicians for home health services.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Coverage for home health services is determined according to individual or group customer benefit.
Payment can be made for covered home health services that a home health agency provides if a physician certifies that:
- The home health services are medically necessary because the individual is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology services, or continues to need occupational therapy; where a patient's sole skilled service need is for skilled oversight of unskilled services the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
- A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
- The services are or were furnished while the individual was under the care of a physician.
As a condition for payment, prior to certifying a patient's eligibility for the home health benefit the certifying physician must document that he or she, or an allowed professional provider has had a face-to-face encounter with the patient. The initial certification is incomplete without them.
Face-to-Face Encounter
The certifying physician must document that he or she or an allowed professional provider had a face-to-face encounter with the patient. In addition to the physician, a certified registered nurse practitioner, who is the member's primary care provider, can document the face-to-face patient encounter and sign the certification.
Other professional providers may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification. In addition to the physician, professional providers who are allowed to perform the face-to-face encounter are:
- A certified registered nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law;
- A certified nurse-midwife as authorized by State law;
- A physician assistant under the supervision of the certifying physician.
Face-to face encounters should be reported with the most appropriate evaluation and management service that accurately reflects the level of care provided.
The face-to-face encounter requirement described above does not apply to the following:
- Private duty nursing (when this service is covered under the member's benefit plan)
- Visits to Mother and Newborn Following "Early Maternity Discharge" as noted under Pennsylvania Act 85 of 1996
- Evaluation-only visits
Encounter Documentation Requirements
The documentation must include the date when the physician or allowed professional provider saw the patient, and a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.
- The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed. In addition to the physician, a certified registered nurse practitioner, who is the member's primary care provider, can document the face-to-face patient encounter and sign the certification.
- It is acceptable for the certifying physician to dictate the documentation content to one of the physician's support personnel to type. It is also acceptable for the documentation to be generated from a physician's electronic health record.
- It is unacceptable for the physician to verbally communicate the encounter to the home health agency (HHA), where the HHA would then document the encounter as part of the certification for the physician to sign.
Timeframe Requirements
- The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.
- In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed professional provider must see the patient again within 30 days after the start of care. Specifically, if a patient saw the certifying physician or allowed professional provider within the 90 days prior to start of care, another encounter would be needed if the patient's condition had changed to the extent that standards of practice would indicate that the physician or a allowed professional provider should examine the patient in order to establish an effective treatment plan.
Exceptional Circumstances
When a home health patient dies shortly after the start of care, before the face-to-face encounter occurs, if it has been determined that a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.
If the below conditions are met, an encounter between the home health patient and the attending physician who cared for the patient during an acute/post acute stay can satisfy the face-to-face encounter requirement.
- A physician who attended to the patient in an acute or post-acute setting, but does not follow the patient in the community (such as a hospitalist) may certify the need for home health care based on his/her contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then transfer/hand off the patient's care to a designated community-based physician who assumes care for the patient; or
- A physician who attended to the patient in an acute or post-acute setting may certify the need for home health care based on his/her contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care.
Recertifications for Home Health Services
When services are continued for a period of time, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of the plan.
The physician must recertify that the individual continues to meet the guidelines for home health services as indicated above. Recertifications must be signed by the physician who reviews the plan of treatment. The form of the recertification and the manner of obtaining timely recertifications are up to the individual home health agency.
NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illnessndition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider's records.
- Link to Provider Resource Center for the Medical Policy Update
06/2011, Physician certification and recertification of home health services: new coverage guidelines explained
10/2011, Certified registered nurse practitioners now eligible to document face-to-face patient encounters for certifying home health services
06/2012, Face-to-face encounter requirements clarified
Facility Bulletin
05/02/2012, Clarification: Face-to-face encounter requirement does not apply to three specific home health situations
- Link to References
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
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Source: https://secure.highmark.com/ldap/medicalpolicy/wpa-highmark/V-21-006.html
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