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Home Health Benefits for the CSHCN Services Program to Change on June 1, 2023

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Effective for dates of service on or after June 1, 2023, home health benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Overview of Benefit Changes

Major changes to the medical benefits include the following:

  • Clarification and updates for skilled nursing (SN), extended SN, and home health aide (HHA) services
  • Updates to some prior authorization guidelines
  • Removal of social work services as a home health benefit

In addition, the current limitation for medical nutritional counseling visits (procedure code S9470) will be clarified as two per rolling year.

SN, Extended SN, and HHA Services

SN services (procedure codes G0299 and G0300) or HHA services (procedure code G0156) will not be authorized for the same day as extended SN services (procedure codes S9123 and S9124).

When a request for SN or HHA services is submitted and extended SN services are already authorized, the request will be reviewed by the CSHCN Services Program.

SN Services and HHA Services

SN services (procedure codes G0299 and G0300) and HHA services (procedure code G0156) may not be provided during overlapping time periods, but they can be requested for the same day.

SN services or HHA services will not be authorized for the same day that a client is receiving Prescribed Pediatric Extended Care Center (PPECC) services (procedure code T1026).

Extended SN Services

Extended SN services (procedure codes S9123 and S9124) require prior authorization. Up to 400 hours of extended SN services may be approved per client per calendar year with documented justification of need and cost effectiveness.

Procedure codes S9123 and S9124 will be denied when billed on the same date of service as PPECC procedure code T1026, any provider.

Updates to Prior Authorization Guidelines

The ordering practitioner’s address will no longer be required with the physician’s orders submitted on the CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form.

Nursing Assessments

A completed client nursing assessment must be submitted with a prior authorization request for SN and HHA services.

The initial nursing assessment must be completed no earlier than five business days before the client’s start of care.

For reassessments when there is no change in the client’s condition, requests received after five business days will be denied for dates of service that occurred before the revision is approved.

Denials

Dates of service on a prior authorization request that are before the submission date or the practitioner signature date will be denied as late submissions. Dates of service requested before the submission date of the home health provider’s plan of care (POC) or before the practitioner signature date on the POC will also be denied.

Social Work Services

Social work services (procedure code G0155) will no longer be a home health benefit of the CSHCN Services Program.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.