Home Health Care Eligibility
To qualify for home health care, a patient must meet at least one of the following criteria:
- Condition expected to improve within a predictable time.
- Requires a skilled therapist to design a maintenance program.
- Needs maintenance therapy delivered safely by a skilled professional.
Collection of Orders and Referrals
When a referral is received, the intake coordinator is responsible for collecting the following documents before the patient is accepted into the Home Health Agency:
Clinical Documentation
History & Physical (H&P) along with recent office visit notes
Medication & Physician Info
Reconciled medication list and primary physician details with order routing info
Home Care Authorization
Home care order including a valid face-to-face encounter
Patient Details
Complete patient demographics for records and billing
Intake Department
The Intake Department gathers essential patient information and coordinates admissions, ensuring timely care and reimbursement.
Reimbursement availability
Assignment of care teams
Accurate scheduling of services
Eligibility & Authorization
Prior Authorizations
If required, our team secures prior authorization using:
- Referral documents
- H&P, progress/surgical notes
- Plan of care (CMS 485)
- Therapy evaluation notes
Insurance Verification
We confirm benefits and eligibility in real-time via payer portals or calls:
- Active coverage confirmation
- Home health coverage details
- Patient cost-share
- Prior authorization status
Assigning Clinicians and Services
After confirming eligibility and collecting the necessary orders, the intake team assigns the appropriate home care disciplines to the relevant clinicians, including nurses, therapists, MSWs, and home health aides. The start of care is scheduled based on the patient's request.
Our Comprehensive Services
Medicare DDE
The Medicare DDE system allows providers to manage and track Medicare claims.
Clinical Documentation
History & Physical (H&P) along with recent office visit notes
QA Verifications
QAPI is a data-driven process where the QA team reviews care orders and alerts clinicians to needed corrections, ensuring high-quality patient care.
Payments
Medicare sends payment details via ERA or SPR, transmitted to banks using ACH or X12 835 formats.
OASIS Review
OASIS is a Medicare-required tool to assess patients, track outcomes, and ensure accurate reimbursement, with trained reviewers completing assessments like start of care and recertification
Rejections and ADRs
Claims may be rejected due to missing documents or incomplete OASIS; timely ADR responses are essential to avoid denials.
Coding
The coding team enters diagnoses into OASIS using referral or MD documents, noting onset dates and severity per agency guidelines.
Orders Management
Orders management ensures signed physician orders are collected before claims submission, using fax, mail, or courier-critical for audits and billing.
Charges and Billing
Home health billers use medical codes to submit RAPs, final claims, perform audits, and process records accurately
Claims Management
Suspended Claims
Suspended claims are under Medicare review and need action only if errors are found and returned
Claims Correction (T-Status)
T-status claims need corrections before Medicare will process them
Rejected Claims
Rejected claims are those that cannot be processed in their current state and must be corrected and resubmitted.
A/R Follow-ups and Denials
Denied claims can't be rebilled and require medical review; most denials result from missing ADR responses or documentation and can be appealed.