Referring Providers

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Referral Information for Skilled Services

Home Health Care is available to everyone, at every life stage, in every New Hampshire city and town.  Our members work with patients from newborns to the elderly and everyone in between. We have agencies that offer skilled care nursing care, physical and occupational services for every type of medical need to homemaker services to provide daily living support.  To find a home health agency in your area, see the search box on the right hand side of this page.

Home health care provides medical treatment for an illness or injury, with the goal of helping you recover, regain your independence and become as self-sufficient as possible. Home health care can also help you live with a chronic condition, like heart disease, COPD, or diabetes.

Is Home Care the Right Choice?

If your patient is in need of short term medical support or relief because of a serious chronic illness, injury or surgery, home health care can make their life easier. Home Health Care can be a blessing for many families.  Whether this is an adult caring for a spouse, an elderly parent, or a newborn with health care challenges, care giving can be overwhelming for the entire family – especially if they don’t know where to turn for answers and support. We can help.

While each agency must determine whether services can be delivered safely at home. Some conditions that affect safety, and therefore would limit the option for home health care are:

1. The patient cannot walk or transfer safely and will be home alone.

2. The patient requires 24-hour care and or supervision and has no adequate caregiver.

3. The patient exhibits behavior that would place him/herself or a provider at risk.

Skilled Home Health Care Qualifying Criteria for Medicare

To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):

  1. The patient must be homebound.
  2. Need skilled services;
  3. Be under the care of a physician;
  4. Receive services under a plan of care established and reviewed by a physician; and
  5. Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP)

Physicians should also note that in accordance with the Patient Protection Affordable Care Act, CMS issued a Final Regulation that went into effect January 1, 2011 whereby Medicare will pay for home health services only when a physician certifies in the home health plan of care that the patient has had a face-to-face encounter (see below) with their physician in the 90 days prior to or within 30 days of the start of services. The primary reason for home health services must be addressed during this encounter.

If a physician works in collaboration with a nurse practitioner or clinical nurse specialist, or supervises a physician’s assistant, the face-to-face encounter may be carried out by that non-physician practitioner who must have documented their clinical findings and communicated those findings to you. However, only a physician may order home health services, certify that a face-to-face encounter occurred, and certify that other eligibility criteria are met (medical necessity and home bound status).

Medicare and Home Care Booklet from CMS

Certifying Patients for the Medicare Home Health Benefit

Homebound Definition

Homebound

Criteria for Homebound Status
CMS advises that an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One:

The patient must either:

  • 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 their place of residence or
  • Have a condition such that leaving his or her home is medically contraindicated.
  • If the patient meets one of the Criteria-One conditions, then the patient must also meet two additional requirements defined in Criteria-Two below.

Criteria-Two: 

  • There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.

Background and Further Clarification on Homebound

Medicare Face-to-Face Policy

The face to face physician encounter must be documented on the home health plan of care, or an addendum to that plan of care. Documentation of the certification of a face-to-face encounter must include:

  • The date of the encounter.
  • Indication that the encounter was related to the primary reason for home health.
  • An explanation of how the clinical findings of the encounter support the need for skilled nursing or therapy services.
  • An explanation of why the clinical findings of the encounter support that the patient is homebound.
  • Your signature and the date of that signature.

Many agencies also provide Medicare-eligible home health aide and medical social worker services in conjunction with nursing, physical therapy or occupational therapy services.

To qualify for the Medicare benefit, a face to face patient/ physician encounter must be made by the physician responsible for certifying home health.  If a physician works in collaboration with a nurse practitioner or clinical nurse specialist, or supervises a physician’s assistant, the face-to-face encounter may be carried out by that non-physician practitioner who must have documented their clinical findings and communicated those findings to you. However, only a physician may order home health services, certify that a face-to-face encounter occurred, and certify that other eligibility criteria are met (medical necessity and home bound status).

  • Related to the primary reason for which the patient requires home health services.
  • Made within 90 days prior to, or within 30 days of, the start of home health.

Home Health Face to Face Documentation Requirements

Medicare Checklist

The following checklist has been developed to serve as a guide to help you determine whether or not a patient is eligible to receive skilled home health care services. Patients may be eligible for covered home care services when any of the following apply to them:

1. Have a complex medical need such as: a new diagnosis, exacerbation of an existing illness (COPD, CHF, Diabetes), home infusion therapy, multiple diagnoses or pain management.

2. Are at risk for problems due to, a history of falls, new, multiple or changed medication. Poor understanding of diseases and symptoms to report to MD.

3. Require skilled nursing nursing treatment at home, such as: catheter care and routine changes, intravenous line care and maintenance, dressing changes for wound care, enteral feedings and tube care, ostomy care and assisted teaching relating to all of the above, as well as many other medical conditions.

4. Recently had surgery or a long hospitalization, and: are at risk for complications of infection, are concerned about safety at home, need instruction in symptoms to report to MD; need physical or occupational therapy to progress to previous level of function, need prosthetic and adaptive equipment training, need initial assessment and monitoring at home.

 Home Care and Medicare booklet from CMS

Medicare Signature Requirements for Health Care Professionals

Medicare Enrollment Guideline for Ordering/Referring Providers