Several types of healthcare providers can refer patients to home health care, but the person who formally certifies the need for services must be a physician, nurse practitioner, physician assistant, or clinical nurse specialist. Beyond these certifying providers, hospital discharge planners, social workers, case managers, and even family members often play key roles in starting the referral process.
Providers Who Can Officially Order Home Health
For Medicare-covered home health services, only certain practitioners have the legal authority to certify that a patient qualifies. Physicians (MDs and DOs) have always held this authority. Since March 2020, the CARES Act permanently expanded that power to nurse practitioners, physician assistants, and clinical nurse specialists. These “allowed practitioners” can now certify patient eligibility, establish the plan of care, and periodically review it, as long as they are practicing within their state’s scope of licensure.
This was a significant change. Before 2020, nurse practitioners and physician assistants could perform the face-to-face encounter with a patient but still needed a physician to sign off on the certification. Now they can handle the entire process independently.
What the Certifying Provider Must Document
Ordering home health care isn’t as simple as writing a prescription. The certifying provider must attest that the patient meets three conditions: they are homebound, they need skilled nursing care or therapy (physical, occupational, or speech), and they are under the provider’s ongoing care.
“Homebound” has a specific meaning. The patient must need assistive devices like walkers or wheelchairs, require help from another person, or need special transportation to leave home. On top of that, leaving home must represent a considerable and taxing effort. Someone who simply prefers to stay home doesn’t qualify.
A diagnosis alone won’t cut it for documentation. The provider needs to connect the patient’s diagnosis, symptoms, and functional limitations to explain why skilled services are necessary and what could go wrong if those services weren’t available. This level of detail matters because incomplete documentation is one of the most common reasons home health claims get denied.
The Face-to-Face Requirement
The certifying provider (or another allowed practitioner) must have a face-to-face encounter with the patient that’s related to the primary reason home health is needed. This visit must happen within 90 days before the start of home health care or within 30 days after care begins. If the referral is based on a new condition that wasn’t evident during a recent visit, the provider must see the patient within 30 days of admission.
The provider then writes a brief narrative describing what they observed during that encounter and how it supports the patient’s homebound status and need for skilled services. This narrative must be signed by the certifying provider personally. A home health agency cannot document the encounter on the provider’s behalf based on a verbal summary.
How Hospital Discharges Trigger Referrals
Many home health referrals originate during hospital stays, and the process typically involves a team rather than a single provider. Discharge planners, who may be nurses, social workers, or dedicated case managers, assess whether a patient will need continued care after leaving the hospital. They coordinate with the patient’s physician or the hospital-based provider to initiate the home health order.
This team approach brings in physical and occupational therapists who evaluate the patient’s functional needs, social workers who help identify the right home health agency and connect families with community resources, and sometimes insurance representatives who confirm coverage. The physician or allowed practitioner still signs the formal certification, but the discharge planning team does much of the groundwork in matching the patient with appropriate services.
Referrals From Outpatient and Community Settings
Not every home health referral starts in a hospital. Primary care providers frequently order home health services for patients whose conditions have gradually worsened, such as someone with heart failure who is increasingly unable to manage medications and monitoring on their own. A specialist, like a surgeon following a joint replacement, might also initiate the referral if the patient needs wound care or physical therapy at home.
In some community-based programs, the referral net is even wider. Depending on the state and the type of services, referrals can come from the patient themselves, a family member or guardian, a mental health provider, or a care coordinator. These informal referrals still require a qualifying provider to complete the clinical certification before services begin, but they can be the important first step that gets the process moving.
Social workers are particularly valuable in outpatient settings. They help patients with complex chronic illnesses navigate insurance requirements, coordinate with home care agencies, make follow-up calls to ensure services are in place, and connect families with additional community resources that go beyond what the home health agency provides.
How Insurance Affects the Process
Medicare requires a physician or allowed practitioner to order home health services and create a plan of care. Some services, equipment, and supplies may also need prior approval before they’re covered. The plan of care must be signed before the home health agency can submit its final claim for payment, though an agency can begin services based on verbal orders or a signed referral with detailed instructions.
Private insurance plans vary more widely. Some follow a process similar to Medicare, while others require pre-authorization, limit the number of covered visits, or restrict which agencies you can use. If you have commercial insurance, check with your plan administrator or benefits coordinator to find out whether home health services require authorization and what documentation your insurer expects from the referring provider.
Timing of the Plan of Care
Home health care operates in 30-day periods. The certifying provider must sign and date the plan of care before the agency submits its final claim for each period. If the signed plan isn’t ready at the very start, the agency can begin services based on the provider’s verbal orders or a detailed signed referral, then obtain the full signed plan before billing.
The plan of care is also reviewed periodically. Each time a patient needs continued home health services, the certifying provider (or another qualified provider if the original one is unavailable) must recertify that the patient still meets the homebound and skilled-care requirements. Providers should review these recertification forms carefully rather than signing them automatically, since the forms sent by home health agencies don’t always contain enough detail about the patient’s current functional status and the reasons they remain homebound.