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Priority:
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Resolution:
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Affects Version/s:
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Fix Version/s:
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Adult Day Health Services Payment Policy
Policy Statement
Adult day health services include day programs for seniors and other adults who need supervision
and health services during the daytime. Adult Day Health programs offer nursing care, therapies,
personal care assistance, social and recreational activities, meals, and other services in a community
group setting. Adult Day Health programs are for adults who return to their homes and care givers
at the end of the day.
In accordance with State of Rhode Island Executive Office of Health and Human Services managed
care contracts, an adult day health program shall mean a comprehensive, nonresidential program
designed to address the biological, psychological, and social needs of adults through individual plans
of health that incorporate, as needed, a variety of health, social and related support services in a
protective setting.
Scope
This policy applies to:
☒
Medicaid
excluding:
Extended Family Planning (EFP)
Children with Special Health Care Needs (CSN) < 18 years of age
Substitute Care (SUB) < 18 years of age
☒
INTEGRITY
☐
Commercial
Prerequisites
All services must be medically necessary to qualify for reimbursement. Neighborhood may use the
following criteria to determine medical necessity:
National Coverage Determination (NCD)
Local Coverage Determination (LCD)
Industry accepted criteria such as Interqual
Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations
Clinical Medical Policies (CMP)
It is the provider’s responsibility to verify eligibility, coverage and authorization criteria prior to
rendering services.
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For more information, please refer to:
Neighborhood’s plan specific
Prior Authorization Reference page.
Neighborhood’s
Clinical Medical Policies
.
Please contact Provider Services at 1-800-963-1001 for questions related to this policy.
Coverage Requirements
Adult Day Health Services are defined as supervision, health promotion and health prevention
services that include the availability of nursing services and health oversight, nutritional dietary
services, counseling, therapeutic activities and case management.
Each member receiving adult day health services must meet, at a minimum, the preventive level of
care as determined by the EOHHS Office of Long Term Service Supports.
Face to face assessment and reassessment with the member’s Primary Care Provider (PCP) is
required annually or if the member’s condition changes
Adult day health services consist of three (3) levels of care:
1.
Basic Level
-
Minimum of four (4) hours per day up to six (6) days per week
Transportation is included in the per diem or half day rate
o
Total transportation not to exceed two (2) hours to and from home
Physical therapy, Occupational therapy, and Speech therapy are not included in the
per diem rate and must be billed separately.
2.
Enhanced Level Non Skilled
-
Criteria outlined above for basic level with the addition of:
o
Daily Assistance with at least 2 Activities of Daily Living(ADL)
or
o
Daily Assistance with at least 1 Skilled Service by a Registered Professional
Nurse (RN) or a Licensed Practical Nurse (LPN)
or
o
Daily Assistance with at least 1 ADL which requires 2-person assist to complete
or
o
Diagnosis of Alzheimer’s disease or other related dementia or a mental health
diagnosis that requires staff intervention due to safety concerns.
3.
Enhanced Level Skilled-
o
Criteria outlined above for Enhanced Level Non Skilled with the addition of
need for skilled services by a physician within the professional disciplines of
nursing, physical, occupational, and speech therapy. Skilled services include but
are not limited to:
Administration of oxygen on a regular and continuing basis when the
participant's medical condition warrants skilled observation (for example,
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when the member has chronic obstructive pulmonary disease or
pulmonary edema)
Insertion, sterile irrigation, and replacement of catheters, care of
suprapubic catheter, or in selected participants, a urethral catheter. A
urethral catheter, particularly one placed for convenience or for control
of incontinence does not justify a need for skilled nursing care. However,
the insertion and maintenance of a urethral catheter as an adjunct to the
active treatment of disease of the urinary tract may justify a need for
skilled care. In such instances, the need for a urethral catheter must be
documented and justified in the member’s medical record (for example,
cancer of the bladder or a resistant bladder infection)
Pacemaker assessment
Physician ordered, daily nurse monitoring specifically related the written
care plan and the need for medical or nursing intervention which may
include: measurement of output, unstable blood glucose and/or blood
pressure or administration of oral or injectable medications that require a
nurse monitoring the dosage, frequency or adverse reactions.
Intravenous, intramuscular, or subcutaneous injection, or intravenous
feeding
Nasogastric-tube, gastrostomy, or jejunostomy feeding
Nasopharyngeal aspiration and tracheotomy care. However, long-term
care of a tracheotomy tube does not, in itself, indicate the need for
skilled services
Treatment and/or application of dressings when the physician
prescribed irrigation, the application of medication, or sterile dressings of
deep decubitus ulcers, other widespread skin disorders or care of
wounds, then the skills of a registered nurse are needed to provide safe
and effective services (including but not limited to ulcers, burns, open
surgical sites, fistulas, tube sites and tumor erosions)
Ostomy care
Provision of maintenance therapy to meet particular needs of a
participant when indicated by the program therapy consultants or the
participant’s physician and is part of a written plan of care
In order to bill Neighborhood Health Plan of R.I.(Neighborhood) for the Enhanced Level, the
adult day care must document they are providing the services required for that level as outlined in
the care plan which must be signed by the participant or legal guardian or representative as well as
completion of the required progress notes.
Exclusions
If admission of the individual to adult day health services would result in the individual
receiving duplicative or substantially identical services as those provided by any other
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Medicaid funded service that the individual has chosen, then the individual will not be
eligible for adult day health services.
Residents of a residential health care facility shall be ineligible for adult day health services
An adult who requires and who is receiving care 24 hours per day on an inpatient basis in a
hospital or nursing home shall be ineligible for adult day health services.
An adult who has partial care/partial hospitalization program services on a particular day is
not eligible for adult day health services on the same day.
Members enrolled in the Personal Choice Program are not eligible for adult day health
services.
Claim Submission
Adult Day Basic Level services should be billed with no modifier.
Adult Day Enhanced Level Non Skilled services should be billed with modifier U1.
Adult Day Enhanced Level Skilled services should be billed with modifiers U1 and U3.
Billable services are subject to contractual agreements, when applicable. Providers are required to
submit complete claims for payment within contractually determined timely filing guidelines.
Adjustments, corrections, and reconsiderations must include the
required forms
. All submissions
must be in compliance with National Claims Standards.
Coding must meet standards defined by the American Medical Association’s Current Procedural
Terminology Editorial Panel’s (CPT®) codebook, the International Statistical Classification of
Diseases and Related Health Problems, 10th revision, Clinical Modification (ICD-10-CM), and the
Healthcare Common Procedure Coding System (HCPCS) Level II.
Member Responsibility
Commercial plans are excluded from coverage. Other products have no member responsibility.
Coding
The following codes may be covered for adult day health services when the adult day criteria set
forth in this policy are met:
Code
Description
S5101
Day care services, adult; per half day
S5102
Day care services, adult; per diem
In addition to the codes listed above Adult Day Enhanced Level of Care must be billed with the
one or both of the following modifiers according to criteria set forth in this policy:
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Code
Description
U1
Medicaid level of care 1, as defined by each state
U3
Medicaid level of care 3, as defined by each state
Disclaimer
This payment policy is informational only and
is not intended to address every situation related to
reimbursement for healthcare services; therefore, it is not a guarantee of reimbursement.
Claim payments are subject to the following, which include but are not limited to: Neighborhood
Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, coding
and documentation guidelines, authorization policies, provider contract agreements, and state and
federal regulations. References to CPT or other sources are for definitional purposes only.
This policy may not be implemented exactly the same way on the different electronic claims
processing systems used by Neighborhood due to programming or other constraints; however,
Neighborhood strives to minimize these variations.
The information in this policy is accurate and current as of the date of publication; however,
medical practices, technology, and knowledge are constantly changing. Neighborhood reserves the
right to update this payment policy at any time. All services billed to Neighborhood for
reimbursement are subject to audit
Document History
Date
Action
9/29/21
Annual Policy Review Date. No Content Changes.
09/14/20
Policy Review Date. Format Change.
09/01/13
Policy Effective Date
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