Under TRICARE, home health agency providers must follow Medicare guidelines and the TRICARE Reimbursement Manual, Chapter 12 when submitting claims for home health care to Health Net Federal Services, LLC (HNFS).
Prospective Payment System
The TRICARE benefit for home health care services closely follows Medicare's Home Health Agency Prospective Payment System (HHA-PPS). Medicare-certified billing is handled in 60-day-care episodes, allowing home health agencies to receive two payments of 60 percent and 40 percent, respectively, per 60-day cycle. This two-part payment process is repeated with every new cycle, following the patient’s initial 60 days of home health care. Medicare updates HHA-PPS rates annually on a calendar year basis.
- 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-PPS reimbursement. The CHAMPUS maximum allowable charge (CMAC) does not apply.
- For pediatric or pregnant beneficiaries who are receiving services from Medicare-certified home health agencies, HHA-PPS reimbursement applies. 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.
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.
Outcome and Information Assessment Set (OASIS)
Medicare-certified home health agencies are required to conduct abbreviated OASIS assessments for beneficiaries who are under the age of 18 or receiving maternity care for payment under the HHA-PPS. This requires the manual completion and scoring of a Home Health Resource Group (HHRG) worksheet in order to generate a Health Insurance Prospective Payment System (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).
Note: OASIS assessments are not required for authorized care in non-Medicare certified HHAs that qualify for Corporate Services Provider status under TRICARE (TRICARE Reimbursement Manual, Chapter 12, Section 1, paragraph 18.104.22.168.2).
Providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim.
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.
- As of Jan. 1, 2019, 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.
- FL 63 must contain the authorization code assigned by the OASIS. Note: This is not an HNFS/TRICARE authorization number. The 18-digit OASIS authorization code contains (example 18JK18AA41GBMDCDLG):
Pos 1–2: Start-of-care date – two-digit year (for example, 18 for 2018)
Pos 3–4: Start-of-care date – alpha code for Julian date (for example, 245 = JK)
Pos 5–6: Date assessment completed – two-digit year (for example, 18 for 2018)
Pos 7–8: Date assessment completed – alpha code for Julian date (for example 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 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 59 days. Dates on all of the lines must fall between the dates in FL 6.
- The claim must contain more than four billable visits to be processed as a full episode. Final claims with four or less billable visits will be processed as a low utilization payment adjustment (LUPA).
- Providers whose home health care claims were previously denied due to incomplete or missing information may resubmit corrected claims to HNFS using these billing guidelines.
*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 home health agency (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 Health Insurance Prospective Payment System (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. The RAP will cover a 60-day episode, beginning on the first date the HHA sees the patient.
- TRICARE pays the RAP at 60 percent of the estimated allowed charges. The estimated allowed charges are based on a number of factors, including the HIPPS condition code 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 files a new RAP (known as a "Subsequent RAP"). 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 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.