Home Health Services Billing Guide - Wa

Home Health (Acute Care Services)DefinitionsThis list defines terms and abbreviations, including acronyms, used in this billing guide.Refer to Chapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Full skilled nursing services – A registerednurse, or a licensed practical nurse under thesupervision of a registered nurse, performsone or more of the following activities duringa visit to a client:Acute care – Care provided by a home healthagency for clients who are not medicallystable or who have not attained a satisfactorylevel of rehabilitation. These clients requirefrequent intervention by a registered nurse orlicensed therapist. (WAC 182-551-2010) Observation Assessment Treatment Teaching Training Management Evaluation(WAC 182-551-2010)Authorized practitioner – A personauthorized to sign a home health plan of care.Brief skilled nursing visit – A registerednurse, or a licensed practical nurse under thesupervision of a registered nurse, performsonly one of the following activities during avisit to a client for:Home health aide – A person registered orcertified as a nursing assistant under chapter18.88 RCW who, under the direction andsupervision of a registered nurse or licensedtherapist, assists in the delivery of nursing ortherapy related activities, or both.(WAC 182-551-2010) An injection A blood draw Placement of medications in containers(WAC 182-551-2010)Case manager – A social worker or a nurseassigned by the Aging and Long-Term CareAdministration (ALTSA) in the Department ofSocial and Health Services to manage andcoordinate the client’s case.Home health aide services – Servicesprovided by a home health aide only when aclient has an acute, intermittent, short-termneed for the services of a registered nurse,physical therapist, occupational therapist, orspeech therapist who is employed by, or undercontract with, a home health agency. Theseservices are provided under the supervision ofthe previously identified authorizedpractitioners, and include, but are not limitedto, ambulation and exercise, assistance withself-administered medications, reportingchanges in a client’s condition and needs, andcompleting appropriate records.(WAC 182-551-2010)Case resource manager (CRM) – A personassigned by the Developmental DisabilitiesAdministration (DDA) to meet with thefamily, conduct an assessment, develop a planwith the client and/or the family, and help toconnect to appropriate resourcesChronic care – Long-term care for medicallystable clients. (WAC 182-551-2010)10

Home Health (Acute Care Services)Home health skilled services – Skilled healthcare (nursing, specialized therapy, and homehealth aide) services provided on anintermittent or part-time basis by a Medicarecertified home health agency with a currentprovider number in any setting where theclient’s normal life activities take place. Seealso WAC 182-551-2000. (WAC 182-5512010)Supervision - Authoritative proceduralguidance given by a qualified person whoassumes the responsibility for theaccomplishment of a function or activity andwho provides initial direction and periodicinspection of the actual act of accomplishingthe function or activity.Long-term care – A generic term referring tovarious programs and services, includingservices provided in home and communitysettings, administered directly or throughcontract by the Department of Social andHealth Services’ Developmental DisabilitiesAdministration (DDA) or Aging and LongTerm Support Administration (ALTSA).(WAC 182-551-2010)Plan of Care (POC) – (Also known as “planof treatment (POT)”). A written documentestablished and periodically reviewed andsigned by both a physician and a home healthagency provider. The plan describes thehome health care to be provided in anysetting where normal life activities takeplace. (For information on clients inresidential facilities whose home healthservices are not covered through theMedicaid agency’s home health program seeWhen does the Medicaid agency pay forcovered home health services?)Review period – The 3-month period theMedicaid agency assigns to a home healthagency, based on the address of the homehealth agency’s main office, during which theMedicaid agency reviews all claims submittedby that home health agency.(WAC 182-551-2010)Specialized therapy – Skilled therapyservices provided to clients that include:physical, occupational, and speech/audiology services. (WAC 182-551-2010)11

Home Health (Acute Care Services)About the Program(WAC 182-551-2000)What is the purpose of the home healthprogram?The purpose of the Medicaid agency’s home health program is to provide equally effective, lessrestrictive quality care to the client, in any setting where the client’s normal life activities takeplace, when the client is not able to access the medically necessary services in the community, orin lieu of hospitalization.Home health skilled services are provided for acute, intermittent, short-term, and intensivecourses of treatment.Note: See What home health services are not covered? for information on chronic, long-termmaintenance care.Who is an eligible home health provider?(WAC 182-551-2200)The following may contract with the Medicaid agency to provide health services through thehome health program, subject to the restrictions or limitations in this billing guide and applicablepublished Washington Administrative Code (WAC): A home health agency that: Is Title XVIII (Medicare)-certifiedIs licensed by the Department of Health (DOH) as a home health agencyContinues to meet DOH requirementsSubmits a completed, signed Core Provider Agreement to the Medicaid agencyHas a home health taxonomy on their provider fileA registered nurse (RN) who: Is prior authorized by the Medicaid agency to provide intermittent nursingservices when a home health agency does not exist in the area a client residesIs unable to contract with a Medicare-certified home health agencySubmits a completed, signed core provider agreement to the Medicaid agencyHas an RN home health taxonomy on their provider fileImportant! Notify the Medicaid agency within ten days of any changes in name,address, or telephone number (see Resources Available).12

Home Health (Acute Care Services)Client Eligibility(WAC 182-551-2020(1))Most Apple Health clients are enrolled in an agency-contracted managed care organization(MCO). This means that Apple Health pays a monthly premium to an MCO for providingpreventative, primary, specialty, and other health services to Apple Health clients. Clients inmanaged care must see only providers who are in their MCO’s provider network, unless priorauthorized or to treat urgent or emergent care. See the agency’s Apple Health managed care pagefor further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for the services.How do I verify a client’s eligibility?Check the client’s Services Card or follow the two-step process below to verify that a client hasApple Health coverage for the date of service and that the client’s benefit package covers theapplicable service. This helps prevent delivering a service the agency will not pay for.Verifying eligibility is a two-step process:Step 1. Verify the patient’s eligibility for Apple Health. For detailed instructions onverifying a patient’s eligibility for Apple Health, see the Client Eligibility, BenefitPackages, and Coverage Limits section in the agency’s ProviderOne Billing andResource Guide.If the patient is eligible for Apple Health, proceed to Step 2. If the patient is noteligible, see the note box below.Step 2. Verify service coverage under the Apple Health client’s benefit package. Todetermine if the requested service is a covered benefit under the Apple Health client’sbenefit package, see the agency’s Program Benefit Packages and Scope of Serviceswebpage.13

Home Health (Acute Care Services)Note: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website at:www.wahealthplanfinder.org2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to:Washington HealthplanfinderPO Box 946Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visitwww.wahealthplanfinder.org or call the Customer Support Center.What are the restrictions?(WAC 182-551-2020(2))The CNP–Emergency Medical Only program covers two skilled nursing home health visits forthose covered under the cancer treatment program and hemodialysis program.Are clients enrolled in an agency-contractedmanaged care organization (MCO) eligible?Yes. Most Medicaid-eligible clients are enrolled in one of the agency’s contracted managed careorganizations (MCOs). For these clients, managed care enrollment will be displayed on the clientbenefit inquiry screen in ProviderOne.All medical services covered under an agency-contracted MCO must be obtained by the clientthrough designated facilities or providers. The MCO is responsible for: Payment of covered servicesPayment of services referred by a provider participating with the plan to an outsideproviderFacility fees associated with dental procedure codes14

Home Health (Acute Care Services)Note: The agency continues to pay for the following through fee-for-service: Professional fees for dental procedures using CDT codes Professional fees using CPT codes only when the provider’s taxonomy startswith 12See the Dental-Related Services Billing Guide and and/or the Physician-RelatedServices/Health Care Professional Services Billing Guide on how to bill professionalfees.Note: A client’s enrollment can change monthly. Providers who are notcontracted with the MCO must receive approval from both the MCO and theclient’s primary care provider (PCP) prior to serving a managed care client.Send claims to the client’s MCO for payment. Call the client’s MCO to discuss payment priorto providing the service. Providers may bill clients only in very limited situations as described inWAC 182-502-0160.Note: To prevent billing denials, check the client’s eligibility prior to schedulingservices and at the time of the service, and make sure proper authorization orreferral is obtained from the agency-contracted MCO, if appropriate. See theagency’s ProviderOne Billing and Resource Guide for instructions on how to verifya client’s eligibility.Managed care enrollmentApple Health (Medicaid) places clients into an agency-contracted MCO the same month they aredetermined eligible for managed care as a new or renewing client. This eliminates a person beingplaced temporarily in FFS while they are waiting to be enrolled in an MCO or reconnected witha prior MCO. This enrollment policy also applies to clients in FFS who have a change in theprogram they are eligible for. However, some clients may still start their first month of eligibilityin the FFS program because their qualification for MC enrollment is not established until themonth following their Medicaid eligibility determination.New clients are those initially applying for benefits or those with changes in their existingeligibility program that consequently make them eligible for Apple Health managed care.Renewing clients are those who have been enrolled with an MCO but have had a break inenrollment and have subsequently renewed their eligibility.15

Home Health (Acute Care Services)Checking eligibility Providers must check eligibility and know when a client is enrolled and with whichMCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s GetHelp Enrolling page. MCOs have retroactive authorization and notification policies in place. The provider mustknow the MCO’s requirements and be compliant with the MCO’s policies.Apple Health – Changes for January 1, 2020Effective January 1, 2020, the Health Care Authority (HCA) completed the move to wholeperson care to allow better coordination of care for both body (physical health) and mind (mentalhealth and substance use disorder treatment, together known as “behavioral health”). Thisdelivery model is called Integrated Managed Care (formerly Fully Integrated Managed Care, orFIMC, which still displays in ProviderOne and Siebel).IMC is implemented in the last three regions of the state: Great Rivers (Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum counties)Salish (Clallam, Jefferson, and Kitsap counties)Thurston-Mason (Mason and Thurston counties)These last three regions have plan changes, with only Amerigroup, Molina, and UnitedHealthcare remaining. There are changes to the plans available in these last three regions. Theonly plans that will be in these regions are Amerigroup, Molina, and United Healthcare. If aclient is currently enrolled in one of these three health plans, their health plan will not change.Clients have a variety of options to change their plan: Available to clients with a Washington Healthplanfinder account:Go to Washington HealthPlanFinder website. Available to all Apple Health clients: Visit the ProviderOne Client Portal website: Call Apple Health Customer Service at 1-800-562-3022. The automated system isavailable 24/7. Request a change online at ProviderOne Contact Us (this will generate an email toApple Health Customer Service). Select the topic “Enroll/Change Health Plans.”For online information, direct clients to HCA’s Apple Health Managed Care webpage.16

Home Health (Acute Care Services)Clients who are not enrolled in an agency-contractedmanaged care plan for physical health servicesSome Medicaid clients do not meet the qualifications for managed care enrollment. These clientsare eligible for services under the FFS Medicaid program. In this situation, each IntegratedManaged Care (IMC) plan will have Behavioral Health Services Only (BHSO) plans availablefor Apple Health clients who are not in managed care. The BHSO covers only behavioral healthtreatment for those clients. Clients who are not enrolled in an agency-contracted managed careplan are automatically enrolled in a BHSO, with the exce

Home health aide services - Services provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by, or under contract with, a home health agency. These