{"ref":"NC-HH-ADM-03","title":"Eligibility, Certification, Face-to-Face Encounter, Homebound Status, and NC Medicaid Coverage","category":"Service delivery","summary":"Sets how the Agency confirms, before and during care, that each patient is eligible under the payer’s rules: for Medicare, the physician or allowed practitioner certification, the face-to-face encounter (90 days before to 30 days after the start of care), homebound status, need for skilled services, a plan of care, and recertification at least every 60 days; for NC Medicaid, the attending physician’s order and certification, the face-to-face attestation, documentation of why services must be given at home, eligibility checks at each service, prior approval where required, and coordination rules.","inShort":["Medicare needs a signed certification and a face-to-face visit with a doctor or allowed practitioner from 90 days before to 30 days after the start of care.","For Medicare, write down specific facts that show the patient is homebound, at the first visit and at every recertification.","For NC Medicaid, check eligibility before each service and write down why care must be given at home.","Check in NCTracks or with the health plan whether prior approval is needed before the first visit.","Tell the supervising nurse if a patient may no longer qualify."],"primaryCitation":"42 CFR §424.22","citations":["NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §424.22","42 CFR §409.42","42 CFR §409.43","42 CFR §440.70","42 CFR §424.516(f)","42 CFR §484.55"],"surveyorAsks":["Show me the certification and the face-to-face encounter documentation for this Medicare patient.","How did you establish that this patient is homebound?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §424.22; NC Medicaid Clinical Coverage Policy 3A, section 5.3.1)","5. Medicare: What the Practitioner Certifies","6. Medicare: Face-to-Face Encounter, Signature and Recertification","7. Medicare: Homebound Status and Other Coverage Conditions","8. NC Medicaid","8.1 Eligibility checks","8.2 Orders, certification and face-to-face attestation","8.3 Why services are given at home","8.4 Prior approval","8.5 Children under 21 (EPSDT)","8.6 Hospice and other NC Medicaid home care services","9. Other Payers","10. Monitoring During the Episode","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"nc-hha","state":"North Carolina","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}