9 common questions about home health eligibility checks and claims

Home health has its own billing rules. The admission decision depends on facts only the payer knows – like whether the patient is already on service with another agency. And care – while reported in 15-minute units – runs in weeks-long periods, not single encounters.

Get an admission detail wrong, and you may not find out until weeks of visits come back as rejected claims.

This guide covers nine things to know when building eligibility checks and claim workflows for home health agencies using Stedi.

1. How can I figure out if a patient is covered by multiple insurance plans?

If you don't know whether the patient has coverage or who the payer is, start with an insurance discovery check. You can run one using just demographics, like name, date of birth (DOB), and (optionally) Social Security Number (SSN).

For patients likely covered by Medicare, such as those 65 or older, an MBI lookup is a more targeted alternative to an insurance discovery check. Like insurance discovery checks, you run MBI lookups using only patient demographics – name, DOB, and either an SSN or the patient's U.S. state. An MBI lookup returns the patient's Medicare Beneficiary Identifier (MBI) and, if found, a complete Medicare eligibility response.

Once you have a payer, run an eligibility check to confirm the patient's first name, last name, DOB, and member ID match what's on file with the payer. Then follow up with a Coordination of Benefits (COB) check to find any additional payers.

COB scenarios are common for home health. For example, older patients are often dual eligible, with both Medicare and Medicaid.

2. Should I use batch or real-time eligibility checks for home health services?

When to use real-time eligibility checks

Use real-time eligibility checks for time-sensitive scenarios, like verifying coverage while a referral is on the phone. If your workflow includes a mix of time-sensitive and time-insensitive scenarios, start with real-time checks to keep things simple.

When to use batch eligibility checks

Use batch eligibility checks if you re-verify coverage on a schedule, like checking your active census at the start of each month, or if you're running thousands of time-insensitive checks at once and building custom logic to handle them. Stedi's batch checks let you submit many requests at once and return the coverage and benefits data in the same fields as a real-time check.

Batch eligibility checks also include automatic retries and longer retry windows, so a single request is more likely to come back with a complete response.

You can submit batch checks using our API or by uploading CSVs to the Stedi portal. For scheduling tips, see How to optimize monthly eligibility refresh checks.

3. Which STCs should I use for home health eligibility checks?

In an eligibility request, a Service Type Code (STC) tells the payer what kind of benefits you're checking. But not every payer supports the same STCs.

Testing is the best way to find out which STCs work for each payer. Our docs cover general STC testing tips. Here's specific guidance for home health agencies.

Step 1. Start with STC 30 (Health Benefit Plan Coverage)

STC 30 is your baseline. You'll use the response to test whether the payer supports more specific STCs.

Many payers fall back to their STC 30 response if you submit an STC they don't support.

Step 2. Test home health STCs

Payers aren't obligated to return home health benefits under STC 30. And STCs for home health services aren't included in the response set required of CAQH CORE-certified payers.

To get home health benefits, you usually need to send a more specific STC. Try one or more STCs from the following table.

Example: Active home health benefit returned for STC 42

{
  "benefitsInformation": [
    {
      "code": "1", // Active coverage
      "serviceTypeCodes": ["42"], // Home Health Care
      "coverageLevelCode": "IND",
      "insuranceTypeCode": "MC", // Medicaid
      "planCoverage": "Home Health Services",
      ...
    },
    ...
  ],
  ...
}

Send one STC per eligibility request. Many payers don't support multiple STCs in a single check – some reject the request, others return a default response or only use the first STC provided.

Step 3. Compare the eligibility responses

Compare the payer's responses for STC 30 and the home health STC you tested.

If an STC returns home health benefits that STC 30 didn't, the payer supports that STC. Use that STC in future eligibility checks for that payer.

Repeat the process for each payer. You can't assume STCs that work for one payer apply to another.

Tip: Use a script to loop and diff

You can script your eligibility requests to speed up the testing process. Loop through candidate STCs and compare the responses against the baseline STC 30 response for the same patient. If you're using Stedi's JSON Eligibility API, you can save the benefitsInformation array for each STC and diff them.

For more tips, see our STC testing docs.

4. Do Medicare eligibility checks require transaction enrollment?

Yes. Providers must complete transaction enrollment with the Centers for Medicare & Medicaid Services (CMS) to run eligibility checks for Original Medicare (Part A and Part B).

You can submit transaction enrollment requests using our API or the Stedi portal, which supports bulk CSV. You can also track requests and handle any follow-up tasks using the API or portal.

If a CMS eligibility check fails because a provider's National Provider Identifier (NPI) isn't enrolled, Stedi automatically submits the enrollment request for you.

Medicare Advantage and commercial payers typically don't require transaction enrollment for eligibility checks. You can confirm whether a payer requires enrollment in the Stedi Payer Network or through the Payers API.

5. Can an eligibility check tell me if a patient is already on service with another home health agency?

For Original Medicare (Part A and Part B), yes – Medicare eligibility checks include period-of-care history that overlaps with the date of service. You can use this history to determine whether the patient is in an active period of care.

For most other payers, no. Payers aren't required to include period-of-care history in eligibility responses, so most commercial payers and Medicaid plans don't. Treat those responses as coverage and benefits data, not admission history.

How periods of care show up in Medicare eligibility responses

To check coverage under Original Medicare, send the eligibility check to CMS using Payer ID CMS and STC 42. The response includes any periods of care for the patient that overlap the service dates in your request.

For Medicare Advantage plans, send eligibility checks to the commercial payer, not CMS. If you already know the patient is on a Medicare Advantage plan, skip the CMS check.

In Stedi's JSON Eligibility API response, these periods show up with other benefits in benefitsInformation objects:

{
  "benefitsInformation": [
    {
      "code": "X", // Health Care Facility
      "serviceTypeCodes": ["42"], // Home Health Care
      "timeQualifierCode": "26", // Episode
      "benefitsDateInformation": {
        "service": "20260601-20260630", // Period start and end dates
        "periodStart": "20260603", // Earliest billing activity (DOEBA)
        "periodEnd": "20260626" // Latest billing activity (DOLBA)
      },
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Provider",
          "entityName": "ANYTOWN HOME HEALTH AGENCY",
          "entityIdentificationValue": "1234567890" // The billing agency's NPI
        },
        ...
      ],
      ...
    },
    {
      "code": "X", // Health Care Facility
      "compositeMedicalProcedureIdentifier": {
        "procedureCode": "G0180" // Home health certification
      },
      "benefitsDateInformation": {
        "periodStart": "20260601" // Certification date
      },
      ...
    },
    ...
  ],
  ...
}

The CMS response may also flag active Medicare Advantage coverage:

{
  "benefitsInformation": [
    {
      "code": "U", // Contact following entity for eligibility or benefit information
      "serviceTypeCodes": ["30"], // Health Benefit Plan Coverage
      "insuranceTypeCode": "HN", // HMO - Medicare Risk
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Primary Payer",
          "entityName": "EXAMPLE MEDICARE ADVANTAGE PLAN",
          "contactInformation": {
            "contacts": [
              {
                "communicationMode": "Telephone",
                "communicationNumber": "8005551234"
              }
            ]
          },
          ...
        }
      ],
      ...
    },
    ...
  ],
  ...
}

If so, run the patient's future eligibility checks against the Medicare Advantage payer, not CMS.

6. Can an eligibility check tell me if prior authorization is required for a home health service?

Usually, yes. Prior authorization – also called preauthorization or precertification – is when a payer requires approval before it covers a service.

To see if a service requires prior authorization, check the authOrCertIndicator field in the benefit entries of our JSON eligibility response:

{
  "benefitsInformation": [
    {
      "code": "1", // Active coverage
      "serviceTypeCodes": ["42"], // Home Health Care
      "authOrCertIndicator": "Y", // Prior authorization is required
      ...
    },
    ...
  ],
  ...
}

If the field isn't included, you can assume prior authorization isn't required.

Some payers also include prior authorization details as free-text notes in the additionalInformation.description field. These notes can clarify or override the authOrCertIndicator value. For example:

{
  "benefitsInformation": [
    {
      "code": "CB", // Coverage basis
      "serviceTypeCodes": ["42"], // Home Health Care
      "additionalInformation": [
        {
          "description": "PRECERTIFICATION REQUIRED FOR HOME HEALTH SERVICES AFTER 30 VISITS"
        }
      ],
      ...
    },
    ...
  ],
  ...
}

The indicator tells you whether prior authorization is required. It doesn't tell you what the payer needs to approve it. For handling U values and free-text notes, see How to check for prior authorization requirements in a 271 eligibility response.

7. Do home health claims use professional or institutional claims?

It depends on the payer and program.

Medicare-certified home health agencies bill Medicare using 837I institutional claims. Many Medicaid and commercial programs for personal care and non-skilled services use 837P professional claims instead. Check each payer's billing instructions for the programs you bill.

You can submit both institutional and professional claims using Stedi's APIs, SFTP, or the Stedi portal.

8. Which codes do Medicare-covered home health visits use?

On Medicare home health claims, each visit is reported with a discipline-specific G-code – a Healthcare Common Procedure Coding System (HCPCS) Level II procedure code that CMS maintains for its programs.

Each code is billed in 15-minute units, and you can only report one G-code per visit, even when the visit includes more than one service.

Each G-code pairs with a revenue code – a standardized 4-digit code identifying the type of room, service, or supply billed on a service line. A procedure code describes the care delivered. A revenue code describes the category the charge falls under, which for home health is the discipline that furnished the visit. Revenue codes always start with 0, 1, 2, or 3.

In the following table, the X in a code like 042X stands in for the last digit. Home health visit lines usually end in 1, as in 0421 for a physical therapy visit charge.

Home health billing codes

Medicare requires you to report G0320-G0322, but they don't count as billable visits and don't affect payment.

For more information, see Chapter 10 of the Medicare Claims Processing Manual. For other commonly used codes, see CGS's list of Home Health Billing Codes.

Certification codes

You'll also see G0179 and G0180 in home health billing as certification codes: G0180 covers the initial certification of the home health plan of care, and G0179 covers recertification.

The certifying physician or practitioner – not the home health agency – bills G0179 and G0180 on professional claims. In a Medicare eligibility response, these codes mark the certification and recertification dates in the patient's period-of-care history.

These G-codes apply to Medicare and plans that follow Medicare billing rules. Medicaid and commercial programs can use different code sets. Check each payer's billing instructions.

9. Does Stedi support Electronic Visit Verification?

No. Stedi is a healthcare clearinghouse. We primarily support standardized transactions that use X12 HIPAA EDI under the hood. Electronic Visit Verification (EVV) isn't covered by HIPAA and doesn't use X12 – it runs on a separate system entirely.

EVV is a way for payers to verify that a home visit happened. It uses Global Positioning System (GPS) tracking and visit-logging software to check who delivered the care, where, and when.

The 21st Century Cures Act requires EVV for Medicaid-funded home health services. Each state designates its own EVV system or aggregator. Medicaid plans may deny claims that don't have a matching verified visit, even if the patient is covered and eligible for care.

Get started with Stedi

If you're building claims or eligibility workflows for home health, Stedi can help.

To get started, sign up for a free sandbox account. It takes less than two minutes. No credit card is required.

Sandbox accounts give you access to mock eligibility checks – including CMS checks – that you can use for testing or integration.

When you're ready, upgrade to production on our pay-as-you-go plan. There are no monthly minimums or setup fees. You only pay for the transactions you use.