Coverage Guidelines

Provider Participation Guidelines

To participate in the Rhode Island Medicaid Program, providers must meet the following requirements:

Providers must be located and be performing services in Rhode Island (except for border communities ).

Providers must be licensed by the Rhode Island Department of Health to provide services. Home Health providers must be certified to participate in the Medicare program.

Recertification

Home Health providers are annually recertified by the Rhode Island Department of Health (RIDOH). The license expiration date for Home Health providers is December 31. Providers obtain license renewal through RIDOH and then forward a copy of the renewal documentation to Gainwell Technologies.  Gainwell Technologies should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program. A provider may appeal to the RIDOH if they do not meet the recertification criteria. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid(CMS).

Reimbursement Guidelines

Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to the Medicaid Program. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program.

Plans of Care

Items and services provided under the Home Health Program must be ordered and furnished under a written Plan of Care. The plan must be signed by the attending physician and incorporated into the agency's permanent record for the patient, which relates the items and services to the patient's condition. The written Plan of Care must meet the following criteria:

Includes the diagnosis and description of the patient's functional limitation resulting from illness or injury.

Specifies the type and frequency of needed service, e.g., skilled nursing services, drugs and medications, special diet, permitted activities, rehabilitation and therapy services, home health aide services, medical supplies equipment and appliances.

Provides a long-range forecast of likely changes in the patient's condition.

Is reviewed by the attending physician in consultation with professional agency personnel every 60 days, or more frequently as the severity of the patient's condition requires. Reviews must be dated and signed by the physician.

The attending physician certifies that the services and items specified in the treatment plan can be provided through a Home Health Agency in the patient's place of residence.

The patient’s condition may be either an episode of acute illness or injury, or a chronic condition requiring home health care under a physician's order. Specifies changes in the plan in writing, signed by the attending physician or by a registered professional nurse on the agency staff pursuant to the physician's oral orders.

Claim Billing Guidelines

All Home Health claims must be submitted on the UB-04 claim form. For claim completion instructions go to Claims Processing.

Claims for an individual recipient should be billed for a calendar month. Multiple units of the same procedure code should be rolled/bundled into one detail. When determining the total time of services provided for the month, follow these instructions for rounding:

1-14 minutes: Round Down to the nearest hour
15-29 minutes: Round Up to the nearest half hour
31-44 minutes: Round Down to the nearest half hour
45-59 minutes: Round Up to the nearest hour

Home Health Aide Services

Home Health Aide Services must be assigned in accordance with a written plan of care/treatment established by a physician and be supervised by a registered nurse or appropriate therapist.

Under appropriate supervision, the Home Health Aide may provide personal care and assistance in the activities of daily living, e.g., helping the patient to bathe, to care for hair or teeth, to exercise and to retrain the patient in necessary self-help skills. During a particular visit, the Home Health Aide may also perform household chores which are incidental to the visit, i.e., changing the bed, light cleaning, washing utensils, assisting in food preparation.

In cases where Home Health Aides/Certified Nursing Assistance are assigned to a client who requires specific therapy, the Home Health Aide must be supervised by the appropriate therapist; however, it is not necessary in these cases to have an additional supervisory visit by a registered nurse to supervise the provision of personal services.

In cases when the Home Health Aide services are not provided in conjunction with Skilled Nursing services, Prior Authorization is required.

Skilled Nursing Services

Skilled Nursing Services are reimbursable by the Medicaid Program when they are related to the care of a Medicaid Program recipient who is experiencing acute or chronic periods of illness and if those services are:

• Ordered by a physician and are included in a plan of treatment established for the patient.
• Required on an intermittent basis.
• Reasonable and necessary for the treatment of an illness or injury.

Skilled Nursing Services are covered when performed by a Registered Nurse and include high risk pregnancy related to preventive prenatal and postpartum services as outlined below:

Skilled nursing services includes the services of a registered nurse employed by or under contact with a Home Health Agency. RN services include assessment of the individual’s health status, identification of health care needs, determination of health care goals and the development of the plan of care. Skilled nursing care includes teaching and counseling and is directed toward the promotion, maintenance and restoration of health. The nurse evaluates responses of the family and individual to nursing interventions to determine the progress towards goal achievement and provider supervision to ancillary personnel.

Pregnancy-Related Preventive Prenatal and Postpartum Skilled Nursing Services

These services must be performed by a registered nurse and include skilled nursing visits rendered to women at high risk of negative pregnancy outcomes and are performed during the prenatal or postpartum period of pregnancy for the purpose of:

Evaluation of medical health status, obstetrical history, present and past pregnancy-related problems, and psychosocial factors such as emotional status, inadequate resources, supportive helping networks, and parenting skills.

The provision for general health education also includes counseling, referral, instruction, suggestions, support and/or observation to monitor for any unforeseen changes in the condition of a prenatal or postpartum woman at high risk. This allows other medical or social services, when necessary, to be instituted during the prenatal or postpartum stage of childbearing.

Home Health Services for well child care or for well prenatal or postpartum care are not reimbursable by Medicaid.  

Documentation Requirements

The following information must be documented in writing and on file with the home health agency as evidence of the medical necessity for pregnancy-related preventive prenatal and/or postpartum skilled nursing services:

An order signed and dated by a licensed physician.

Individual recipient case records documenting one or a combination of the high risk indicator(s).

An individual recipient plan of care which describes the pregnancy-related preventive prenatal and postpartum skilled nursing service(s) being provided and concurrently identifies the particular skilled nursing service(s) rendered.

All documentation shall be subject to review by authorized EOHHS personnel upon request.

Physical, Occupational and Speech Therapy Services

All therapy services must be prescribed by a physician and and Speech Therapy performed by a licensed therapist. Therapy services must be Services directly related to an active plan of care designed by the prescribing physician and of such a level of complexity and sophistication that the judgment, knowledge and skills of a qualified therapist are required. All therapies must be medically necessary under accepted standards of medical practice to the treatment of the patient’s condition.

Covered Services

The following table lists all covered services/procedure codes for Home Health Services that are reimbursable through the Medicaid Program. The table below shows the procedure code, service description, and units allowed per day. Reimbursement rates will be listed on the fee schedule.