Home Care Services

Covered Services

1. Home Health Aide (HHA)
2. Home care rehabilitation therapies
   1. Occupational therapy with a registered occupational therapist (OT) or Certified Occupational Therapy Assistant (COTA)
   2. Physical therapy with a physical therapist (PT) or physical therapy assistant (PTA)
   3. Respiratory therapy
   4. Speech therapy
3. Skilled Nursing Visits (SNVs)
4. Home Care Nursing (HCN)

Services must be:

1. Provided to an eligible member
2. Medically necessary
3. Ordered by a physician, advanced practice registered nurse (APRN) or physician assistant (PA)
4. Provided in the member’s own residence or in the community where normal life activities take the person
5. Documented in a written care plan

PrimeWest Health does not cover waiver services requested by a home care provider (refer to Home and Community Based Services [HCBS] Elderly Waiver).

For a member to be eligible to receive home health services covered under the Medicare benefit, the law requires that a health care provider certify in all cases that the member is confined to his/her home. A member shall be considered “confined to the home” (homebound) if one criterion from Criteria Group One is met and both criteria from Criteria Group Two are met.

Criteria Group One

The member must either:

1. Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave his/her place of residence; or
2. Have a condition such that leaving his/her home is medically contraindicated.

If the member meets one of the Criteria One conditions, the member must also meet both requirements defined in Criteria Group Two below.

Criteria Group Two

1. The member must have a normal inability to leave home; and
2. Leaving home must require a considerable and taxing effort. If the member does, in fact, leave the home, the member may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to, the following:
   1. Attendance at adult day centers to receive medical care
   2. Ongoing receipt of outpatient kidney dialysis
   3. The receipt of outpatient chemotherapy or radiation therapy

Eligible Providers

1. Home health agency
2. HCN
3. RN
4. Independent registered nurse (RN) or independent licensed practical nurse (LPN) who can attest to all statements on the Home Care Nurse – Individual LPN or RN Provider Assurance Statement (DHS-7099)
5. Independent LPN with a Class A license from MDH

Provider requirements: Provider is limited to services that are allowed under the licensure or certification of the agency and agency practitioners. Class A licenses are no longer issued by the Minnesota Department of Health; effective 2014, providers must have the Comprehensive Homecare License.

Qualifying Services

Qualifying services must be all of the following:

1. Provided to an eligible member
2. Medically necessary
3. Physician-ordered services provided to PrimeWest Health members in their own residence, that is other than a hospital, SNF, or ICF
4. Documented in a written care plan, which is reviewed by the member’s physician at least once every 60 days for home health agency or HCN services, or at least once every 365 days for personal care services

Face-to-Face Encounter Requirements

All home health services require a start of service face-to-face visit. Services include home health aide visits and home care therapies. Home care therapies are occupational, physical, respiratory, and speech languages therapies.

Skilled nurse visits provided for a onetime perinatal visit do not require a face-to-face visit.

A face-to-face visit can occur through telehealth.

At the start of home health services, a face-to-face visit must meet the following criteria:

1. Be for the primary reason the member requires home health services
2. Occur within 90 days before or 30 days after the start of services
3. Be completed by a qualified provider

If a qualified provider other than the physician completes the start of service face-to-face visit, he/she must send or transmit his/her documentation to the physician, including clinical findings.

Documentation of face-to-face visits

The physician ordering the home health services must document the following:

1. That all clinical findings of the face-to-face visit are included in the member’s medical record
2. The correlation between the face-to-face visit and the associated home health services
3. That the face-to-face visit occurred within the required timelines
4. The practitioner who completed the face-to-face visit and the date of the visit

Home health agencies must do the following:

1. Retain the required documentation as part of the member’s medical record
2. Bill only when the required documentation is part of the member’s medical record
3. Submit the required documentation to PrimeWest Health or designee upon request

Plan of Care

The care plan is a written description of professional nursing services needed by the member as assessed to maintain and/or restore optimal health.

The orders or plan of care must do all of the following:

1. Specify the disciplines providing care
2. Specify the frequency and duration of all services
3. Demonstrate the need for the services and be supported by all pertinent diagnoses
4. Include member’s functional level, medications, treatments, and clinical summary
5. Be individualized based on member needs
6. Have realistic goals
7. Subsequent plans of care must show member response to services and progress since the previous plan was developed
8. Changes to the plan of care are expected if the member is not achieving expected care outcomes

Combination PCA and Other Home Care Services

PCA combinations include one or more of the following PrimeWest Health fee-for-services: SNV, HHA, and/or HCN along with PCA services. Home care services must be medically necessary and cost effective. The home care rating determines the maximum dollar amount allowed for all home care services. See Home Care Nursing Service Decision Tree (DHS-4071C) and PCA Decision Tree (DHS-4201) for more information.

Home Care and Hospice Election

The hospice benefit:

1. Is a comprehensive package of services offering palliative care support to terminally ill individuals and their families
2. Is designed to supplement the care provided by primary care givers such as family (as the patient defines family), friends, and neighbors
3. Is not intended to replace the supportive services provided by primary caregivers
4. Is not intended to duplicate health services or supports that relate to a pre-existing condition
   1. Example: A home care service or supply is required for a condition unrelated to the terminal condition (e.g., quadriplegia, schizophrenia, cerebral palsy) and does not supplant or duplicate the covered hospice benefit
5. Is not intended to cover medical needs that arise during the period of the hospice benefit that are unrelated to the terminal illness

Generally, the determination about whether a service duplicates a hospice benefit service will be made as part of the hospice provider’s general responsibility to provide care coordination. The hospice care coordinator assumes the lead responsibility for collaborating with the county case manager, home care agency, physician, or other providers providing the services that are outside of the hospice benefit.

For further information and details about the hospice benefit, see Hospice Services. 

Individualized Educational Plan (IEP)

Refer to Individualized Education Program (IEP) Services for additional information regarding IEP services. Covered IEP services include nursing services, PCA services, physical therapy, occupational therapy, speech-language pathology (SLP), mental health services, special transportation, and assistive technology devices.

The child may also be receiving these services through Medical Assistance (Medicaid). When services are provided through the school, they are considered IEP services and billed as such. IEP services are not considered or billed as home care or therapy.

Coordination of IEP services and home care services are assessed on a 24-hour non-school day.

A parent/guardian may choose to use home care or PCA services in the school rather than have the school bill for the education plan service.

1. Services must be listed in the child’s IEP/individualized family service plan (IFSP)/individual interagency intervention plan (IIIP); and
2. Permission must be given by the parent/guardian in the care plan and retained by the provider in his/her records.

Non-Covered Services

1. Services that are not ordered by the member’s physician, APRN, or PA
2. Services that are not specified in the member’s service plan or care plan
3. Services provided without authorization from DHS when required
4. Services that have already been paid by Medicare, health plans, health insurance policies, or any other liable third party at more than the MHCP allowable amount
5. HCN or PCA services provided to non-pregnant MinnesotaCare members over age 18
6. Services to other members of the member’s household
7. Home care services included in the daily rate of a community-based residential facility where the member is residing
8. Services that are the responsibility of the foster care provider under the terms of the foster care placement agreement and administrative rules
9. HCN and PCA Services provided when the number of foster care residents is greater than six, unless conditions are met for granting a variance for a sibling group.
10. Home health agency services without the required documentation of a face-to-face visit

Information for All PrimeWest Health Home Care Providers – Service Agreement Quick Reference Guide

Getting Started

1. Obtain all health insurance coverage information.
2. Verify member eligibility; see Eligibility & Benefits.
3. If the member is eligible for a waiver, contact the member’s county case manager or lead agency.
4. If the member is PrimeWest Health-eligible without a waiver, follow the process outlined in the Quick Reference section.

Bill Medicare and other insurance before billing PrimeWest Health.

Authorization Guidelines

Request prior authorization for all of the following:

1. More than two face-to-face PCA assessment visits conducted by the county Public Health nurse (PHN), per member, per calendar year
2. More than one service update assessment visit by the county PHN per member, per calendar year

Face-to-Face Assessments

The county PHN may conduct up to two face-to-face assessments per member per calendar year when:

1. A member is requesting PCA services for the first time;
2. A member’s condition changes significantly;
3. PCA services change(s) is needed; or
4. A member is using the PCA Choice option.

The county PHN or certified PHN under contract with the county must do the following:

1. Complete the assessment within 30 days of request
2. Conduct all assessments for PCA services
3. Conduct service updates and temporary service increase requests for PCA services
4. Provide information about options available in the PCA program
5. Develop a service plan appropriate to the member’s needs
6. Recommend and provide referral information about other services as appropriate
7. Assist the member in identifying the most appropriate professional (if selected) to supervise the PCA
8. Recommend the necessary amount of PCA services and supervision of PCA services (if selected) to PrimeWest Health, including requests for temporary service increases from PrimeWest Health
9. Provide the member or responsible party with a list of enrolled PCPOs and PCA Choice providers, if requested

A county PHN agency that is also a provider of PCA services cannot conduct assessments for its own PCA recipients. These county agencies must contract with:

1. Another PHN agency; or
2. An independent certified PHN:
   1. Not employed by or under contract with the county agency; or
   2. Not under contract with an enrolled PCPO to conduct the assessment and reassessments.

An assessment must include the Personal Care Assistance (PCA) Assessment and Service Plan (DHS-3244) and any additional documentation as necessary to substantiate services. See the PCA Assessment and Service Plan Instructions and Guidelines (DHS-3244A) for instructions on completing the form.

Changes in Medical Status or Primary Caregiver Availability

Changes in medical status include, but are not limited to, the following:

1. Change in health
2. Change in level of care
3. Addition of service(s)
4. Change in physician orders
5. Change in living arrangement (i.e., recent facility placement)
6. Change in primary caregiver’s availability

Changes are temporary (45 days or less) or long-term (up to 365/366 days). Documentation must support the requested change in service.

Multiple Providers of Services

Services can be rendered by more than one provider agency at the same time. Each provider agency can bill for the same type of service on the same day.

1. Daily codes (i.e., HCN and rehabilitation therapies) must be billed in consecutive date spans only, to avoid duplicative billing.
2. 15-minute codes may be billed by more than one provider, per date of service (DOS).

Each provider must submit the MA Home Care Technical Change Request (DHS-4074) indicating all of the following:

1. All provider names and numbers
2. DOS for each provider
3. The number of units to be used by each provider

Change in Provider

A member may change services delivery from one provider to another provider.

Discontinuing Provider

To discontinue using a provider, fax the MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free), with all of the following information:

1. Member identification (ID) number
2. Service Agreement number being adjusted
3. Provider ID number of agency discontinuing services, last DOS with agency discontinuing services
4. Last DOS with agency discontinuing services
5. Total units to be transferred to the new agency

Initiating New Provider

To begin using a new provider, fax the MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free) with all of the following information:

1. Member ID number
2. Service Agreement number being adjusted (if available)
3. Provider ID number of agency beginning services
4. Date services will begin with the new agency

In the event the discontinuing provider does not submit the MA Home Care Technical Change Request (DHS-4074) release, the member, responsible party, or legal guardian must provide a signed written statement indicating the last DOS and the name of the new provider agency. Provide a copy to the provider agency terminating and initiating services.

Change in Living Arrangement

Admission to a Facility

When a member is admitted to a facility, the provider must submit the MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free), indicating the following:

1. The last date service was provided
2. The total number of units provided up to that date

Discharge from a Facility to the Community

When a member is discharged from a facility into the community, the provider must submit the MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free), indicating:

1. The first date service will be reinstated
2. The total number of units requested

Change in Member Identification (ID)/ Personal Member Identifier (PMI) Number

When a member’s ID/PMI number changes, the provider must submit the completed MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free), indicating all of the following:

1. Previous PMI number
2. Previous name
3. New PMI number
4. New name
5. Date of birth (DOB)
6. Date of change to the new PMI number

Technical Change/Correction

Technical changes/corrections include, but are not limited to, incorrect:

1. Provider name/ID number
2. Member name/DOB
3. Healthcare Common Procedure Coding System (HCPCS) code/units/rate
4. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes

Submit the correct information on the MA Home Care Technical Change Request (DHS-4074) and use the “Comments” section to explain why the correction is being requested.

Skilled Nursing Visit (SNV), Home Health Aide (HHA), Rehabilitation Therapy, and Home Care Nursing (HCN)

When a change or correction is need for SNV, HHA, rehabilitation therapy, and HCN services, the provider must submit the completed MA Home Care Technical Change Request (DHS-4074) to 1-866-431-0804 (toll free). The submitted form must do the following:

1. State the correct information
2. Contain documentation in the “Comments” section stating the reason the correction is being requested

Non-Waiver Home Care to Waiver Home Care

The county case manager must do the following:

1. Provide a Service Request Form to the provider

Recovery of Excessive Payments

PrimeWest Health will seek monetary recovery from home care providers who exceed coverage and payment limits. This does not apply to services provided to a member at the previous level pending an Appeal.

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Updated_11/30/2023