A home care referral form is how a physician or hospital discharge planner tells a home health agency that a patient needs skilled services at home. To complete one correctly for a Medicare patient, document that the patient is homebound and needs skilled care, record a qualifying face-to-face encounter, and fill in the clinical and demographic fields the agency will carry into the CMS-485 Home Health Certification and Plan of Care. Then send it, with supporting records, through a HIPAA-compliant channel to the receiving agency.
The form itself is not standardized. Many agencies use their own intake document or an electronic portal. Whatever the format, the information collected feeds into CMS-485, which the certifying physician must sign before the agency can bill Medicare.1Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual Chapter 26 – CMS-485 Home Health Certification and Plan of Care Getting the fields right at the referral stage is what prevents weeks of back-and-forth later.
Confirm the Patient Qualifies Before You Refer
Medicare pays for home health only when the patient is homebound and needs skilled care. Both must be true, and both must be documented in a way the agency can defend if the claim is reviewed.
Homebound does not mean bedridden. A patient qualifies if an illness or injury restricts the ability to leave home without help from another person or a device such as a wheelchair, walker, or cane, or if leaving home is medically contraindicated. The statute requires a “normal inability to leave home” where doing so takes “considerable and taxing effort.” Occasional absences are permitted. Trips for medical treatment, including outpatient dialysis, chemotherapy, radiation, and licensed adult day-care programs that provide medical services, never disqualify a patient. Short, infrequent non-medical absences, like a religious service, a haircut, or a family funeral, are also allowed.2Office of the Law Revision Counsel. 42 USC 1395n – Procedure for Payment of Claims of Providers of Services Describe the condition clearly on the referral; vague homebound language is one of the fastest ways to trigger a denial.
The patient must also need at least one skilled service: skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy. The physician must establish a plan of care and remain responsible for home health treatment throughout the certification period.3eCFR. 42 CFR 424.22 – Requirements for Home Health Services Skilled care is work that can only be performed by or under the supervision of a licensed professional, such as wound care, intravenous injections, catheter management, or rehabilitation therapy.4Centers for Medicare & Medicaid Services. Custodial Care vs Skilled Care
Custodial care alone will not qualify. Help with bathing, dressing, cooking, and laundry is not covered on its own because non-licensed caregivers can safely perform those tasks.4Centers for Medicare & Medicaid Services. Custodial Care vs Skilled Care If the patient needs both, build the referral around the skilled component. A home health aide can then be added to the plan of care for personal care tasks as long as a qualifying skilled service is also being delivered.
Document the Face-to-Face Encounter
The certifying physician must document a face-to-face encounter with the patient before certifying home health. The visit can be performed by the certifying physician or by a qualified non-physician practitioner such as a nurse practitioner or physician assistant. It must occur no more than 90 days before home health care starts, or within 30 days after care begins.5Centers for Medicare & Medicaid Services. Medicare Home Health Face-to-Face Requirement
The encounter must relate to the primary reason for home health. Documentation needs the date of the visit and a brief narrative explaining how the clinical findings support both homebound status and the need for skilled care. This is a condition of payment. If the narrative is missing, or if it does not connect the encounter to the home health need, Medicare will not pay the claim.5Centers for Medicare & Medicaid Services. Medicare Home Health Face-to-Face Requirement
Telehealth encounters can satisfy the requirement. Federal legislation extended Medicare telehealth flexibilities through December 31, 2027, allowing patients to receive non-behavioral health services at home without geographic restrictions, and audio-only visits remain eligible through the same date.6Telehealth.HHS.gov. Telehealth Policy Updates Note the telehealth modality in the documentation and address homebound status and skilled need with the same specificity you would after an in-person visit.
Fill In the Form
Pull the clinical fields directly from the patient’s electronic health record. The following data points are standard across intake forms and all required for CMS-485:
- Patient demographics: full legal name, date of birth, address, sex, and Medicare Health Insurance Claim Number or Medicare Beneficiary Identifier.
- Start of care date, entered as month/day/year.
- Diagnoses: the principal diagnosis most related to the plan of care plus all pertinent secondary diagnoses, each coded in ICD-10 with the date of onset or most recent exacerbation.
- Medications: a complete list with dosage, frequency, and route of administration.
- Services requested: the specific skilled disciplines needed (skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social work) along with anticipated frequency and duration.
- Functional limitations: objective descriptions of the patient’s ability to walk, dress, bathe, transfer, and perform daily tasks.
- Durable medical equipment and non-routine supplies the physician is ordering.
- Safety measures: fall prevention, infection control, and other physician instructions.
- Nutritional requirements and known drug allergies.
Functional limitations deserve particular attention. “Limited mobility” is not enough to build a defensible plan of care around. Something like “patient unable to ambulate more than 10 feet without a rolling walker and standby assist” is specific and measurable, and it will carry through the plan of care intact.1Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual Chapter 26 – CMS-485 Home Health Certification and Plan of Care
The physician’s signature on the completed plan of care is what unlocks billing. Electronic signatures are accepted, but the system has to include protections against modification and comply with applicable standards. A signature attestation can resolve a missing signature in the record, but it cannot be used to backdate the plan of care.7Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements
Submit the Referral
Send the referral through a HIPAA-compliant channel. Most home health agencies accept intake by encrypted fax, secure physician portal, or direct upload. Hospitals are required to give patients a list of Medicare-participating home health agencies during discharge planning, so the patient or family can choose an agency before the referral is transmitted.
Attach everything the agency will need in one transmission: the face-to-face encounter narrative, recent hospital discharge summaries, operative notes when relevant, and the current medication list. Sending the complete packet together avoids the back-and-forth that stalls intake. The agency will confirm receipt and begin processing immediately.
What the Agency Does Next
Federal regulations require the home health agency to conduct an initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician-ordered start of care date, whichever applies.8eCFR. 42 CFR 484.55 – Condition of Participation: Comprehensive Assessment of Patients A registered nurse, physical therapist, speech-language pathologist, or occupational therapist conducts the visit and completes a comprehensive assessment of the patient.
The agency then finalizes the plan of care. By regulation it must include all pertinent diagnoses, the types and frequency of services, prognosis, rehabilitation potential, functional limitations, permitted activities, all medications and treatments, safety measures, nutritional requirements, and the patient’s risk for emergency department visits or hospital readmission with interventions to address those risks.9eCFR. 42 CFR 484.60 – Condition of Participation: Care Planning, Coordination of Services, and Quality of Care If anything on the referral was incomplete, the agency will come back to the physician before seeking the signature.
Medicare pays for home health in 30-day periods, and the physician must recertify the patient at the end of each period if services continue. The plan of care itself must be reviewed and revised as the patient’s condition requires, and at minimum every 60 days.9eCFR. 42 CFR 484.60 – Condition of Participation: Care Planning, Coordination of Services, and Quality of Care Each recertification needs a fresh physician signature, so keep the lines of communication open with the agency throughout the care period.
What Causes Referrals and Claims to Get Denied
Medicare claim denial data from the second quarter of 2025 shows that three documentation failures drive the overwhelming majority of home health denials:
- Requested records not submitted, roughly 38 percent of denied claims. The agency failed to send the documentation Medicare asked for during review.
- No plan of care or certification, about 30 percent. The physician never signed the plan of care, or the certification paperwork was absent.
- Face-to-face encounter requirements not met, around 16 percent. The encounter was not documented, happened outside the allowable window, or the narrative did not tie the clinical findings to the home health need.
Smaller shares involve missing physician orders for specific services, documentation that does not support medical necessity for therapy, and billed visits that were not documented in the record. Almost all of these problems are fixable at the referral stage. A complete referral with a clear face-to-face narrative, specific functional limitation data, and a signed plan of care eliminates the top three categories outright.
A Note on Self-Referral
Federal law prohibits a physician from referring a patient to a home health agency in which the physician or an immediate family member holds a financial interest. Home health services are listed as a “designated health service” under the physician self-referral statute, and if a prohibited referral occurs, the agency cannot bill Medicare or any other payer for those services.10Office of the Law Revision Counsel. 42 USC 1395nn – Limitation on Certain Physician Referrals A financial relationship includes ownership, investment, and compensation arrangements. Limited exceptions exist, but the default is simple: a financial stake in the agency puts the referral off limits.
If Services Are Terminated
When a home health agency decides that Medicare-covered services are ending, it must issue a Notice of Medicare Non-Coverage to the patient. The notice explains the patient’s right to a fast-track appeal and lists the phone number for the Beneficiary and Family-Centered Care Quality Improvement Organization that handles the first review.11Centers for Medicare & Medicaid Services. FFS and MA NOMNC/DENC The BFCC-QIO decides within 72 hours. If it upholds the termination, the patient can request expedited reconsideration from a Qualified Independent Contractor, and after that an Administrative Law Judge hearing. The patient’s physician should be ready to submit a written statement explaining that stopping care will jeopardize the patient’s health, and should be available by phone during the review.