Medicare and Medi-Cal Eligibility, Certification, Face-to-Face Encounter, and Homebound Status
For a Medicare-certified agency, sets out how Medicare eligibility is checked and documented: the qualifying conditions (confined to the home, under the care of a physician or allowed practitioner, need for a qualifying skilled service, under a plan of care, served by a participating agency) (42 CFR §409.42); certification and the face-to-face encounter no more than 90 days before or within 30 days after the start of care (§424.22(a)); recertification at least every 60 days (§424.22(b)); supporting documentation; the financial relationship bar; the Notice of Admission within 5 calendar days (§484.205(j)); and signatures before billing. For Medi-Cal and other payers, eligibility and authorization are checked under the payer’s current rules.
- Policy number
- CA-HH-ADM-03
- Version
- 1.0
- Main rule
- 42 CFR §424.22
- Library
- California home health · 58 policies
- Category
- Service delivery
- Sections
- 21
In short
- For Medicare patients, write down exactly why the patient is homebound, at the first visit and at the full assessment.
- Record how often and why the patient leaves home. Medical visits and religious services do not stop them being homebound.
- A face-to-face visit with the doctor or practitioner must happen 90 days before or 30 days after care starts. Tell your supervisor if it is missing.
- Tell your supervisor if the patient may no longer be homebound or no longer needs skilled care.
- For Medi-Cal and other plans, make sure visits are authorized before you schedule them.
What's inside
21 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §424.22)
- 5. Eligibility Screening at Intake
- 6. Verifying Homebound Status and Skilled Need
- 7. Certification
- 8. The Face-to-Face Encounter
- 9. Supporting Documentation
- 10. Recertification
- 11. Financial Relationships
- 12. Notice of Admission and Signatures Before Billing
- 13. Medi-Cal and Other Payers
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- Show me how you verified that this Medicare patient is homebound, at the initial visit and at the comprehensive assessment.
- Where is the face-to-face encounter documented, who performed it, and on what date?
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