CommercialPrior AuthMedium impact
Home Health Aides (CPB 0218, reviewed 2026-04-22)
Aetna·Physical Therapy, Occupational Therapy, Speech Therapy +3 more·Medical Policy
Effective date
May 6, 1998
We identified it
Aug 19, 2026
Summary
Aetna updated its Home Health Aide policy (CPB 0218) clarifying that home health aide services are medically necessary only when provided in conjunction with skilled home health care and directly supporting those services. The policy establishes a 6-month authorization limit (3 months initial + 3 months extension) and requires practices to inform members of alternative services after 6 months of continuous use.
Action Required
Before May 6, 1998 (if not already implemented): Billing and authorization teams must update systems to enforce the 6-month authorization limit for home health aide services. Specifically: (1) Configure billing software to flag authorizations approaching 6 months of cumulative use for codes 99509, G0156, S9122, T1004, and T1021; (2) Require prior authorization documentation confirming home health aide services are paired with skilled services (nursing, PT/OT, speech therapy); (3) Deny claims for non-covered services including babysitting, general house cleaning (except immediate member area), and transportation; (4) After 6 months of service, require providers to document alternative care options discussed with member/caregiver (personal care, companion aide). Authorization team must reject initial authorizations exceeding 3 months and extension requests exceeding an additional 3 months. Failure to enforce these limits will result in claim denials and potential overpayment recovery.