Under TRICARE, home health agency (HHA) providers must follow Medicare guidelines and the TRICARE Reimbursement Manual, Chapter 12 when submitting claims for home health care.
Please review this page for billing details on:
- Prospective Payment System
- Episodes/Periods of Care
- Split Percentage Payments and Requests for Anticipated Payments (RAPs)
- Outcome and Information Assessment Set (OASIS)
- Claim Requirements
- Home Health Agency Care: Physician's Order to Final Claim
- Home Health Value-Based Purchasing Demonstration
Prospective Payment System
The TRICARE benefit for home health care services closely follows Medicare's Home Health Agency Prospective Payment System (HHA-PPS). TRICARE has adopted Medicare’s Home Health Patient-Driven Groupings Model (PDGM) for home health services beginning on or after Jan. 1, 2020. The unit of payment has changed from 60-day episodes of care to 30-day periods of care, and eliminates therapy thresholds for use in determining home health payment.
Authorizations for home health services, Outcome and Information Assessment Set (OASIS) assessments and updates to patient care plans remain on a 60-day basis.
Episodes/Periods of Care
For home health care that begins on or after Jan. 1, 2020, the unit of payment is based on the calendar year (CY) national, standardized 30-day payment amount.
Medicare updates rates annually on a calendar year basis.
Split Percentage Payments and Requests for Anticipated Payments (RAPs)
Except for low utilization home health agencies, providers must submit an initial claim, also called a Request for Anticipated Payment (RAP) or "no-pay RAP," for periods of care on or after Jan. 1, 2021. This establishes the home health period of care and is required every 30 days thereafter.
For periods of care on or after Jan. 1, 2021, the upfront split percentage payment on an initial RAP claim is 0%.
For periods of care prior to Jan. 1, 2021:
- HHAs participating in Medicare prior to Jan. 1, 2019 will continue to receive RAP payments. The upfront split percentage payment will be 20% on a RAP and 80% on a final claim.
- HHAs who began participating in Medicare on or after Jan. 1, 2019 will receive an entire payment with the final claim.
- HHAs with low utilization (2–6 visits per 30-day period) will be paid a standardized per visit payment instead of payment for a 30-day period of care.
Note: Claims recoupment will be initiated if a final claim is not received within 90 days of the statement “From” date or 60 days from the “Paid” date of the RAP.
Outcome and Information Assessment Set (OASIS)
Home health providers are required to include the Health Insurance Prospective Payment System (HIPPS) code on claims. This is done by inputting OASIS data through a grouper program in the HHA’s billing software or the CMS-provided Java-based Home Assessment Validation and Entry (jHAVEN) tool.
The HHA PPS case-mix system will utilize the PDGM case-mix classification model. This model consists of 432 unique case-mix groups called Home Health Resources Groups (HHRGs). These HHRGs are represented as HIPPS codes and are made up of the following five components:
- admission source
- clinical group
- functional impairment level
- comorbidity adjustment
Continue to report HIPPS codes with revenue code 0023.
- For pediatric (under age 18) and pregnant beneficiaries, Medicare-certified home health agencies are required to conduct abbreviated OASIS assessments. This requires the manual completion and scoring of an HHRG worksheet in order to generate a HIPPS code. The abbreviated 23-item assessment (as opposed to the full 79-item comprehensive assessment) provides the minimal amount of data required to generate the HIPPS code, a required element on home health claims (see below). The abbreviated OASIS HHRG worksheet can be found in the TRICARE Reimbursement Manual, Chapter 12, Addendum B.
- If there is not a Medicare-certified home health agency available, HNFS may authorize skilled therapy, social work or skilled nursing home health services to a non-Medicare certified, but state-licensed agency that is under a Corporate Services Provider participation agreement. In this instance, CMAC reimbursement would be allowed and OASIS assessments are not required.
- For non-pregnant adults (18 years of age or greater) who are receiving services from Medicare-certified home health agencies, TRICARE only allows for HHA-PDGM reimbursement. The CHAMPUS maximum allowable charge (CMAC) does not apply.
Note: This guidance does not apply to home health services provided to active duty family members under the Extended Care Health Option–Extended Home Health Care (ECHO-EHHC) benefit. Reimbursement for services covered under ECHO-EHHC is based on the CMAC.
Low Utilization Payment Adjustment (LUPA)
Medicare-certified HHAs providing fewer than the threshold of visits (LUPA thresholds ranging from 2–6 visits) specified for the period’s HHRG will be paid a standardized per visit payment instead of a payment for a 30-day period of care. A RAP is not required for LUPA periods of care.
The HIPPS code from the OASIS is needed to determine if the period of care meets the LUPA threshold.
- For patients under the age of 18, the OASIS collection is not required by Medicare but completion of the abbreviated OASIS is required to generate the HIPPS code.
- PDGM LUPA thresholds are available under the applicable CY Home Health Final Rule.
Under PDGM, providers must bill in non-overlapping 30-day periods of care.
Tips for filing a RAP*:
- The bill type in Form Locator (FL) 4 of the UB-04 is always 322.
- The “To” date and the “From” date in FL 6 must be the same and must match the date in FL 45.
- FL 39 must contain value code 61 and the Core-Based Statistical Area code of the beneficiary’s residential address.
- Home health agencies in rural areas must also include value code 85 and the associated Federal Information Processing Standards (FIPS) state and county code where the beneficiary resides.
- There must be only one line on the RAP, and it must contain revenue code 023 and 0 dollars. On this line, FL 44 must contain the HIPPS code. The quantity in FL 46 must be 0 or 1.
- A Treatment Authorization Code (TAC) is not required.
Tips for filing a final claim:
- The bill type in FL 4 must always be 329.
- In addition to the blocks noted for the RAP above, each actual service performed with the appropriate revenue code must be listed on the claim form lines. The claim must contain a minimum of five lines to be processed as a final request for anticipated payment. The dates in FL 6 must be a range from the first day of the episode, plus 29 days. Dates on all of the lines must fall between the dates in FL 6.
- If the LUPA threshold is met, the period of care is reimbursed at the full 30-day national standard payment amount. If the LUPA threshold is not met, the period of care is reimbursed at the CY per-visit payment amount. Providers whose home health care claims were previously denied due to incomplete or missing information may resubmit corrected claims to Health Net Federal Services, LLC (HNFS) using these billing guidelines.
- A Treatment Authorization Code (TAC) is not required.
*Billing tips are based on current Centers for Medicare & Medicaid Services (CMS) guidelines. Please refer to www.cms.gov as requirements may change.
Home Health Agency Care: Physician's Order to Final Claim
- The physician writes an order for home health care. This can include skilled nursing or physical, occupation or speech therapy.
- The HHA obtains a pre-authorization for home health care. The authorization will be for a 60-day episode.
- The HHA staff visits the patient at home and completes an assessment known as OASIS.
- Using OASIS, the 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 (RAP). The RAP will cover a 30-day episode, beginning on the first date the HHA sees the patient.
- If the patient’s care is terminated prior to the end of the 30-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 the period of care will not meet the LUPA threshold, they may skip this process and file a no-RAP low utilization payment adjustment (LUPA), 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.
Home Health Value-Based Purchasing Demonstration
Retroactive to Jan. 1, 2020, TRICARE adopted the Centers for Medicare & Medicaid Services (CMS) Home Health Value-Based Purchasing (HHVBP) model for home health agencies (HHAs) in nine U.S. states, four of which are in the TRICARE West Region (see TRICARE Operations Manual, Chapter 29, Section 6). TRICARE's HHVBP demonstration ended Dec. 31, 2021.
Participation in the demonstration was mandatory for all TRICARE-authorized HHAs (network and non-network) that are Medicare-certified and provide services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington.
Under the HHVBP model, CMS determines a payment adjustment based upon the HHA Total Performance Score (TPS), a measurement of quality performance.
A payment adjustment report or PAR is provided once a year to each of the HHAs by CMS.
Submittng TPS and PAR Reports
HHAs that provided services in the above-listed states must submit TPS and PAR reports to the appropriate TRICARE contractor by Dec. 31 each year in order to avoid financial penalty.