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Home Health Agency (HHA) Billing Tips


If you’re an HHA provider who has Medicare patients, it may help to know filing HHA claims with TRICARE mirrors Medicare. You must file both a RAP (Request for Anticipated Payment) and a Final Claim, and make sure a HIPPS code is on the claims.

 

If you’re not familiar with Medicare, it might be helpful to speak with the person who handles Medicare billing or coding in your office. The  Medicare HHA calculator is also a helpful billing tool.

 

Tips for filing a Request for Anticipated Payment (RAP):

  • The bill type (in block 4) is always 322 or 332.
  • The date in block 6 cannot be a range. The "To" date and "From" date must be the same, and must match the date in block 45.
  • Block 39 must contain code 61 and the CBSA code of the beneficiary.
  • There must be only one line on a RAP, and it must contain revenue code 023 and zero dollars. On this line, block 44 must contain the HIPPS code. The quantity in block 46 must be 0 or 1.
  • Block 63 must contain the 18-digit authorization code assigned by the OASIS. This is not the TRICARE managed care contractor authorization number. The 18-digit number should contain (Example- 07JK08AA41GBMDCDLG):


· Pos 1-2: Start-of-care date - two digit year i.e. 07 for 2007,

· Pos 3-4: Start-of-care date- alpha code for Julian date Julian date 245 JK

· Pos 5-6: Date assessment completed - two digit year 08

· Pos 7-8: Date assessment completed - alpha code for Julian date 001 AA

· Pos 9: Reason for assessment 04 4

· Pos 10: Episode Timing - Early = 1, Late = 2 01 1

· Pos 11: Clinical severity points - under Equation 1 7 G

· Pos 12: Functional severity points - under Equation 1 2 B

· Pos 13: Clinical severity points - under Equation 2 13 M

· Pos 14: Functional severity points - under Equation 2 4 D

· Pos 15: Clinical severity points - under Equation 3 3 C

· Pos 16: Functional severity points - under Equation 3 4 D

· Pos 17: Clinical severity points - under Equation 4 12 L

· Pos 18: Functional severity points - under Equation 4 7 G

Tips for a Final Claim:

  • The bill type (in block 4) must always be 329 or 339.
  • In addition to the blocks above (same as the RAP), each actual service performed must be listed on the lines. The dates in block 6 must be a range from the first day of the episode plus 59 days. Dates on all the lines must fall between the dates in block 6.

 

How HHA works

  • The physician writes an order for home health care. This can include skilled nursing or physical, occupation or speech therapy.
  • The Home Health Agency (HHA) obtains a pre-authorization for home health care. The authorization will be for a 60-day episode.
  • HHA visits patient at home and completes an assessment known as OASIS (Outcome Assessment Information Set).
  • Using OASIS, HHA determines the HIPPS code that applies to the patient. The HIPPS is used to identify the patient’s condition and plan of treatment when filing the claim.
  • The HHA files the initial claim, called the RAP (Request for Anticipated Payment). The RAP will cover a 60-day episode, beginning on the first date the HHA sees the patient.
  • TRICARE pays the RAP at 60% of the estimated allowed charges. The estimated allowed charges are based on a number of factors, including the patient’s condition code (HIPPS) and the MSA (geographical data) submitted on the claim.
  • After 60 days the HHA files the final claim and is paid the balance of the actual allowed charges. If the patient needs more care, the provider obtains a new authorization and a new RAP (known as a "Subsequent RAP") is also filed. The provider must update the patient’s condition at this time.
  • If the patient’s care is terminated prior to the end of the 60-day episode, the HHA files a final claim. The system calculates the correct final payment. If an overpayment has been made, the system will automatically initiate a refund request.
  • If the HHA knows in advance that there will be four or fewer visits, they may skip this process and file a No-RAP LUPA (Low Utilization Payment Adjustment), itemizing the actual visits.
  • Once the HHA is issued an authorization for a 60-day episode, most claims for home services and supplies must be billed through the HHA.


Exceptions
  • Providers designated as Corporate Service Providers (CSP) are exempt from the new claim filing rules and may continue billing as always.
  • Beneficiaries enrolled in the CCTP (Custodial Care Transition Policy) Program are exempt from the new claim filing rules and may continue billing as always.

 

Home Health Care Definitions

Admission Date:  date of first service in a period of continuous care


 

CBSA: Core-Based Statistical Area

Episode of Care:  60-day unit of payment

 

HHA:  Home Health Agency

 

HIPPS:  Health Insurance Prospective Payment System

 

LUPA:  Low utilization payment adjustment

 

No-RAP LUPA:  Only a claim, not a RAP, is submitted for an episode because the HHA knows the episode will be four visits or less.

 

OASIS:  Outcome Assessment Information Set (also refers to the software used to bill Medicare HHA)

 

Outlier:  indicator for exceptional high cost cases

 

PEP:  Partial Episode Payment – reduced episode payment that is made when episode is less than 60 days; used with transfers to another HHA or when patient is admitted to hospital

 

RAP:  Request for Anticipated Payment

 

SCIC:  Significant Change in Condition

 

 

 


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