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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
The rules say that reassessment at least every 30 days (performed in conjunction with an ordered therapy 
service): At least once every 30 days, for each therapy discipline for which services are provided, a qualified 
therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, 
and compare the resultant measurement to prior assessment measurements. The therapist must document in the 
clinical record the measurement results along with the therapists determination of the effectiveness of therapy, 
or lack thereof. You can find this information in the Medicare Benefit Policy Manual, Chapter 7 - Home Health 
Services, 40.2.1 - General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, ii. Reassessment at least every 30 days (performed in 
conjunction with an ordered therapy service). 
 
The rules say that under the home health prospective payment system as refined by the Patient-Driven 
Groupings Model, a case-mix adjusted payment for a 30-day period of care is made using one of 432 HHRGs. 
On Medicare claims, these HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) 
codes. HIPPS code rates represent specific characteristics (or case-mix) on which Medicare payment 
determinations are made. HIPPS codes are used in association with special revenue codes used on institutional 
claims submitted to A/B MACs (HHH). One revenue code is defined for every Medicare prospective payment 
system that uses HIPPS codes. For home health claims, this is revenue code 0023. HIPPS codes are placed in 
HCPCS/Accommodation Rates/HIPPS Rate Codes field of the claim. You can find this information in the 
Medicare Claims Processing Manual, Chapter 10 - Home Health Agency Billing, Section 10.1.8 - Coding of 
HH PPS Case-Mix Groups on HH PPS Claims: HHRGs and HIPPS Codes. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.