Home health referral processing turns a faxed referral into a first visit: log the referral, confirm the orders, the face-to-face encounter note, homebound status and the discharge summary are present, check insurance, request anything missing, and schedule the start of care. For Medicare patients, federal rules set when the first visit and the certification paperwork must happen.
What a home health referral includes
A home health referral is the set of pages a hospital, physician office or other facility sends to ask a home health agency to start care. A complete one usually holds an order for home health services, a face-to-face encounter note, information that supports homebound status, a discharge summary when the patient is leaving a facility, and insurance details.
The order says what the patient needs: skilled nursing, physical therapy, speech-language pathology or occupational therapy, and often how often. For Medicare, the certification rules in 42 CFR 424.22 on eCFR list what a physician or allowed practitioner must certify, including that the patient needs intermittent skilled nursing, physical therapy or speech-language pathology services and is "confined to the home".
The face-to-face encounter note shows that a practitioner saw the patient for the reason home health is needed. It has its own section below because it is the page most often missing or incomplete.
Homebound status is rarely a separate form. It usually appears as a statement in the order, the encounter note or the discharge summary describing why leaving home takes considerable effort. Intake staff need to find where the packet says it, not decide it themselves.
The discharge summary describes the hospital or facility stay: diagnoses, procedures, medications at discharge and follow-up instructions. It is often the richest page in the packet and the one clinicians at the agency read first. What fields a discharge summary holds, and how they are pulled into structured form, is covered in the guide to discharge summary extraction.
Beyond those pages, a home health packet often includes a face sheet with demographics and insurance, a medication list, recent lab results and therapy notes. The page-by-page layout of a general referral packet, including the fields every referral order should carry, is in the guide to the referral order and its required fields.
Home health referral timeline to start of care
The home health referral timeline runs from the moment the fax arrives to the first visit, called the start of care. For Medicare patients, the conditions of participation set the outer limit: the initial assessment visit happens within 48 hours of referral, within 48 hours of the patient's return home, or on the ordered start of care date.
That 48-hour window comes from 42 CFR 484.55 on eCFR, which also requires the comprehensive assessment to be completed "no later than 5 calendar days after the start of care". Everything an intake team does has to fit inside those limits, which is why speed at the front of the process matters.
The table below lays out a typical path. The regulatory limits come from the eCFR sections named in the table. The internal target times are examples a fictional agency might set for itself, not requirements.
| Step | Example internal target | Document needed at this step | Regulatory limit (Medicare) |
|---|---|---|---|
| Referral received and logged | Within 1 hour of the fax | The referral fax itself | None stated |
| Packet reviewed for completeness | Within 4 hours | Order, face-to-face note, discharge summary, face sheet | None stated |
| Insurance checked | Within 4 hours, in parallel with review | Face sheet or intake form with member ID | None stated |
| Missing documents requested | Same day as review | A written list of what is missing | None stated |
| Referral accepted and visit scheduled | Within 24 hours | Complete order with services and frequency | None stated |
| Initial assessment visit (start of care) | Within 48 hours | Signed or verbal order, patient address and contact | Within 48 hours of referral or return home, or on the ordered date (484.55) |
| Comprehensive assessment completed | Within 5 days of start of care | Clinician's assessment | No later than 5 calendar days after start of care (484.55) |
| Face-to-face encounter documented | Before billing | Encounter note with date | No more than 90 days before or within 30 days after start of care (424.22) |
| Certification and plan of care signed | As soon as the plan of care is set | Plan of care for signature | When the plan is established or as soon as possible after (424.22) |
The order of the middle steps varies. Many agencies run the completeness review and the insurance check side by side, because waiting on one to finish before starting the other uses up the 48-hour window.
Face-to-face encounter documents in home health referrals
Face-to-face encounter documents show that a qualified practitioner saw the patient in person, or by an allowed telehealth visit, for the main reason the patient needs home health care. For Medicare, the encounter must take place no more than 90 days before the start of care or within 30 days after it, and the certifying practitioner must document the date.
42 CFR 424.22 on eCFR names who may perform the encounter: a physician, a nurse practitioner, a clinical nurse specialist, a physician assistant or a certified nurse-midwife, as state law allows. It also allows telehealth under the Medicare telehealth rules. The encounter must relate to the primary reason for home health.
For intake staff, the practical questions are simpler than the rule:
- Is there an encounter note at all? Many referrals arrive with an order and no encounter note.
- Does it carry a date? An undated note cannot be checked against the 90-day and 30-day window.
- Is the date in range? Count from the expected start of care date.
- Does it relate to the reason for home health? An encounter for an unrelated problem does not meet the rule. That judgement belongs to clinical staff, not intake.
- Who performed it? The note should name the practitioner and their role.
The regulation also says what the certification can rest on. The certifying practitioner's own medical record supports it, and for patients admitted to home health straight from a hospital or post-acute facility, that facility's records can also be used. Documentation from the home health agency itself can be used only when other medical record entries corroborate it and the certifier signs and dates it.
Encounter notes reach an agency in several ways. Some arrive inside the hospital discharge packet as a progress note or a discharge summary section. Others come later from the patient's community physician, often as a separate fax days after the referral. Intake should track the encounter note as its own checklist item with its own status, so a referral is not marked complete just because an order arrived.
Who signs home health orders, and when?
Home health orders and the plan of care are signed by the physician or allowed practitioner who establishes the plan. For Medicare, that practitioner must sign and date the certification when the plan of care is established, or as soon as possible after. Verbal orders are allowed, but they must be written down and later authenticated by the ordering practitioner.
The plan of care rules sit in 42 CFR 484.60 on eCFR. The plan must be established and signed by a physician or an allowed practitioner acting within their state license, and it must list diagnoses, the services, supplies and equipment needed, visit frequency and duration, medications and treatments, measurable goals and more. It must be reviewed at least every 60 days, or sooner if the patient's condition changes.
Verbal orders are common at start of care. A hospitalist or community physician calls in the order so the first visit can happen inside the 48-hour window. Under 484.60, only staff authorized by state law and agency policy may accept a verbal order, the order must be recorded in the plan of care, and the nurse or other qualified practitioner who takes it must sign, date and time it. The ordering practitioner then authenticates and dates it. The regulation leaves the deadline for that authentication to state law and agency policy.
In practice, the signature chase is where many home health referrals stall after the first visit. The plan of care goes out by fax for signature, waits in a physician office, and comes back weeks later or not at all. A tracking log with the date sent, the date of each follow-up and the date returned shows which practitioners need a call.
A common complication is that the referring practitioner is not the one who will sign the plan of care. A hospitalist may order home health at discharge while the patient's community physician will oversee ongoing care. The referral packet should say who will follow the patient. If it does not, that is a question to send back on the first day.
How do you check insurance on a home health referral?
Checking insurance on a home health referral means confirming the patient's coverage is active, identifying whether the plan is traditional Medicare, a Medicare Advantage plan, Medicaid or a commercial plan, and finding out whether the plan requires approval before care starts. Do it while the completeness review runs, because a coverage problem can change whether the agency accepts the referral.
Start with the member ID and payer name from the face sheet or intake form, and confirm them against the payer's eligibility source. Check that the patient's name and date of birth on the referral match what the payer has on file, since a mismatch at this stage turns into a rejected claim later.
Whether authorization is needed depends on the payer. Medicare Advantage plans and Medicaid programs set their own rules for home health. When they do require prior authorization, the CMS fact sheet on the Interoperability and Prior Authorization final rule (CMS-0057-F) says impacted payers, which include Medicare Advantage organizations and Medicaid and CHIP programs, must send decisions within 72 hours for expedited requests and seven calendar days for standard requests. The steps and paperwork of a request are covered in the guide to prior authorization for insurance.
Traditional Medicare has its own review program for home health in some states. The CMS Review Choice Demonstration for Home Health Services page lists Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, where agencies choose between pre-claim review and postpayment review. An agency in one of those states that chose pre-claim review sends its documentation for review before the final claim, so the referral paperwork needs to be in order early.
The documents a payer asks for in a request usually overlap with the referral packet: the order, the encounter note, clinical notes and the plan of care. Which fields to pull from each, and what a person should check before submission, is laid out in the guide to prior authorization document extraction.
Home health referrals that arrive incomplete at hospital discharge
Home health referrals that arrive at hospital discharge are the ones most likely to be incomplete, because they are sent fast, often late in the day, by staff who are discharging several patients at once. The agency then has 48 hours to start care with a packet that may lack an order, an encounter note or a discharge summary.
The gaps follow a pattern. These are the ones intake teams see most, and what to send back for each:
- Discharge summary not yet written. The hospital sends the referral before the physician finishes the summary. Request it by name, with the patient's discharge date, and ask when it will be signed.
- No face-to-face note. The order arrives alone. Ask whether the encounter happened during the stay and request the note, or ask which community practitioner will see the patient within 30 days of start of care.
- Order without services or frequency. "Home health eval and treat" with no discipline listed. Ask which disciplines are ordered and whether a verbal order can be given now.
- No practitioner who will follow the patient. The hospitalist will not sign ongoing orders. Ask who the community practitioner is, with a fax number.
- Medication list that conflicts with the discharge summary. Flag it for clinical staff rather than choosing one.
- Insurance details missing or out of date. The face sheet shows a plan the patient left. Ask the hospital case manager to confirm.
- Pages from another patient. A batch fax from a busy discharge unit can mix patients. Treat those pages as a misdirected fax, following the steps in the guide to what to do with a misdirected medical fax.
Send one written request that lists every missing item, rather than calling once per item. Address it to the case manager or discharge planner named on the referral, and log the time it went out so the 48-hour clock is visible to everyone.
Discharge summaries are one of the document types Schema Care reads, turning diagnoses, procedures, medications and follow-up instructions into fields with a confidence score and a link to the source line. Agencies can see how low-confidence fields reach a reviewer in the human review workflow.