Criteria for Home Health Care

Home Health Care (HHC) Eligibility Criteria

Inclusion Criteria

Home Health care :

Health services that Authorized by DoH and designed to be performed for home bound
patients in their residence.

Criteria for Approval :

1. Patient is Home bound; and

2. Patient is in need of health care and defined as skilled health services that by their
nature requires the skills of a registered nurse or the involvement of health care
professionals to be provided safely and effectively which are necessary to maintain or
improve the patients current condition ; and
3. Patient referred by DoH licensed consultant or specialist physician whose specialty
related to the patient diagnosis.

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 HHC Eligibility Criteria
Exclusion Criteria

Criteria for Rejection :

1. Patient is not considered home bound; or

2. The individualized assessment does not demonstrate such a necessity for skilled
health care, including where services needed do not require skilled nursing care or
therapy and they can be performed safely and effectively by the patient family or
unskilled care givers; or

3. Custodial ,Geriatric or child care that provided for the comfort and convenience of the
patient , family or; or

4. Non health services which do not require continued administration by trained medical
personnel (i.e. personal care including help in the activities of Daily Living).

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 HHC Eligibility Criteria
Definitions

Patient Plan of Care:

An individualized Plan of care devised through a multi-disciplinary team with supporting

documentation for each patient as per DoH standards (Appendix 2). A patient may have
simultaneous skilled and custodial needs. In these circumstances, only those services and
supplies provided in connection with the skilled care are to be considered as such.

The treatment plan for skilled health services should include but not limited to:

1.Any applied therapies;

2.The frequency of the treatment consistent with the therapeutic goals;
3.The potential for a patient’s recovery to a defined level of health within a predictable period
of time, if applicable;
4.The time frame in which the prescribing physician shall re-evaluate the patient’s status and
reassess the medical necessity of ongoing treatment, and
5.To distinguish if the treatment is to improve, maintain, provide palliative relief, or to slow in
the deterioration of a patient’s status.

Note: Medical necessity and the desired results of skilled care must be clearly documented
by a written treatment plan approved by the treating specialist/consultant physician . The
determination of medical necessity must be based on DoH standard.

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 HHC Eligibility Criteria
Definitions

Skilled health Services:

Health service that by its nature requires the expertise of a registered nurse or the
involvement of health care professionals and defined according to the type of services,
the staff best suited to provide those services safely and effectively.

In determining whether a service requires the skills of health care professionals, the
reviewer must considers

 The inherent complexity of the service,

 The condition of the patient ,and
 The accepted standards of medical and nursing practice.

Non-skilled health Services:

 Services that do not require continued administration by trained medical personnel in

order to be delivered safely and effectively.
 Maintenance Program: A program with the goals to maintain the current functional
status or to prevent decline in function rather than to provide therapeutic treatment.
 Health services that can be trained by health care professional for unskilled personnel.

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 HHC Eligibility Criteria
Definitions

Custodial care :

Is the provision of services and supplies for activities of daily living that can be provided
safely and reasonably by individuals who are neither skilled nor licensed medical
personnel .The need for such care could arise from a specific physical condition, general
frailty, or mental incapacity (such as Alzheimer's or other forms of dementia)..

Care giver:

Is unskilled person who is not licensed by DoH and may be nominated or employed by
the patient to assist and care for the patient on a day to day basis.

Notes:
1. The eligibility for HHS are not only based on the diagnosis, type of condition, degree of
functional limitation, or rehabilitation potential but the consideration should be given
to the complexity of care and the required medical supervision.
2. The following conditions do not cause unskilled care to be reclassified as skilled.
a. The absence of a caregiver to perform a service; or
b. The patient is unable to perform an activity independently; or
c. Based only on the request of the patient or a family member.

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 HHC Eligibility Criteria
Health Services in Relation to The Domain of Care
Domain Non-Skilled
- Administration of Oral medications,
eye drops, ointments, suppositories,
inhalation/nebulization and statutory
dose of SC injections (i.e. insulin and
Medication long term low MW heparin) that not
requiring constant attention
of medical personnel.
-Oral feeding including dysphagia
feeding.
-Stable bolus feeding by nasogastric,
gastrostomy or jejunostomy tube
Nutrition/
Hydration
which would include cleaning and
stoma care (Note: skilled care,
supervision or observation may be
required if feedings are not stable).
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Skilled
-Administration of adjustable dose of
SC injection(i.e. Sliding scale
Insulin), that requires administration
and monitoring by a RN.
- Intravenous infusion (IV),
intramuscular injections (IM). and
Venepunctures.
-Continuous mechanical pump
GT/JT feeding.
-NGT, GT or JT feeding intolerance.
-complicated stoma care.
-Insertion and replacement of
nasogastric tubes.
-Total parenteral feedings (TPN).
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 HHC Eligibility Criteria
Health Services in Relation to The Domain of Care
Domain Non-Skilled
- Routine administration of medical
gases after a regiment of therapy
has been established, i.e.
CPAP/BiPAP, adjustment of oxygen
flow rates and/or mode of delivery
based upon Oximetry , according to
prescribed treatment protocol.
- Routine use of small volume
Respiratory nebulizers, simple chest
therapy physiotherapy.
- Chronic uncomplicated oral or
tracheal suctioning.
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Skilled
- Initiation of and changes in
regimens involving
administration of medical gases
- Insertion and replacement of
tracheal cannula.
- Frequent daily suctioning as a
part of complicated
tracheostomy care.
- Ventilator management and
periodic assessment for changes
in the patient’s condition,
particularly in situations where
the patient’s respiratory status
may change suddenly and
unpredictably.
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 HHC Eligibility Criteria
Health Services in Relation to The Domain of Care
Domain Non-Skilled
- Prophylactic and palliative skin
care.
- Changes of dressings for non-
infected postoperative or chronic
skin conditions e.g. grade I or II
pressure ulcers.
Skin &
wound care - General maintenance care in
connection with a plaster cast
(skilled supervision or observation
may be required where the
individual has pre-existing skin or
circulatory conditions or needs to
have traction adjusted).
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Skilled
- Treatment of burns.
- Management of grade III or IV
pressure ulcers .
- Complex and/or sterile dressing
changes .
- Primary dressing for therapeutic
or protective covering which is
applied directly to a wound that is
for the treatment for a wound
caused by, or treated by a
surgical procedure or wound
debridement.
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 HHC Eligibility Criteria
Health Services in Relation to The Domain of Care
Domain Non-Skilled
- Routine services to maintain
satisfactory functioning of
indwelling urethral catheters.
- Clean, non-sterile catheter
Bowel and insertion.
bladder
- Clean, non-sterile intermittent
catheterization.
- General maintenance care of
colostomy and ileostomy
Routine observation where the
indication is part of a longstanding
pattern of the patient's condition
Observation which itself does not require skilled
and/or
services and there is no attempt to
Monitoring
change the treatment or initiation
of additional medical procedures.
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Skilled
- Catheter care in the presence of
any GUS
deformities/complications that
may be affected by cath.
- Sterile catheterization.
- Bowel and bladder training.
- Rectal enemas in IBD, Malignancy
and after bowel surgery.
There is a reasonable potential for
a future complication ,acute episode
of illness ,abnormal /fluctuating vital
signs, oedema, symptoms of drug
toxicity, abnormal/fluctuating lab
values or respiratory changes on
auscultation that justify skilled
observation and assessment
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 HHC Eligibility Criteria
Health Services in Relation to The Domain of Care

Domain Non-Skilled Skilled

General supervision of exercises, Episodes of physical therapy as a

which have been taught to the part of treatment or rehabilitation
individual and do not require skilled program where there must be a
rehabilitation personnel for their reasonable expectation that a
performance. This includes, but is member’s condition will improve
not limited to: significantly in a reasonable and
generally predictable period of time.
- repetitive exercises to maintain
function, improve gait, or
Physical maintain strength or endurance.
Therapy
- passive exercises to prevent
immobility complications.

- assisted walking.

- Routine care in connection with

braces and similar devices.

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Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
Care Domain and Scoring Grid to Determine the
Level of Homecare services
 Care Domain and Scoring Grid to Determine the Level
of Homecare services

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 Claims Common Denials

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Claims Common Denials
Billing Methodology

*Denial Code Denial Description Examples

AUTH-001 Prior approval is required and was not obtained  Incorrect approved Authorization number.
 Incorrect approved SRVC level.

AUTH-004 Service(s) is (are) performed outside authorization Service date in claim level before the effective date or after
validity date the expiry date.

CLAI-012 Submission not compliant with contractual agreement  Per Diem without activity service - Homecare provider
between provider & payer must report the services which performed within the
per diem as CPT code (with zero amount)
 Wrong quantity in additional activity lines – CPT
quantity doesn’t match the per diem quantity.

CODE-012 Encounter type inconsistent with service(s) / diagnosis  Using outpatient Encounter “1” instead of Homecare
encounter “12”

CODE-010 Activity/diagnosis inconsistent with clinician specialty  Wrong clinician ID in per diem and Activity line
Refer to Homecare per diem billing rules, circular Ref No.
PRD/MC/CA/16/UAE-119

BENX-002 Benefit maximum for this time period or occurrence has  Exceeding the approved Authorized quantity
been reached
CODE-013 Invalid principal diagnosis (for example E-codes)  Using Invalid ICD10 code as principal diagnosis.
Example – B96.1 Klebsiella pneumonia as the cause of
disease classified elsewhere.

*Denial code published by Department of Health (DOH), please refer to DOH website
 Questions and Answers

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