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.
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.
Unlike Medicare’s PDGM model, TRICARE still requires providers to submit a Treatment Authorization Code. See below.
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 60-day episodes of care that began on or before Dec. 31, 2019, and spanned into 2020, the payment will be the calendar year (CY) national, standardized 60-day episode payment amount. The latest 60-day episode should end no later than Feb. 29, 2020. Subsequent home health services, if required, will be reimbursed based on 30-day periods of care.
For home health care that begins on or after Jan. 1, 2020, the unit of payment will be the 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), and a final claim.
- 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 and Treatment Authorization Code (TAC) 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.
For 30-day periods of care on or after Jan. 1, 2020, 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 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).
- 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.
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.
- 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). Reference the TRICARE Reimbursement Manual, Chapter 12, Section 4 regarding format of the treatment authorization code.
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.
- The claim must contain three or more billable visits to be processed as a full episode. Final claims with less than three billable visits will be processed as a LUPA and will be reimbursed at the 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.
*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 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.