3.0 POLICY
3.1 Background
3.1.1 With the
advent of the HHA PPS and home health Consolidated Billing (CB),
Medicare had to establish a means of identifying a “primary” HHA
for payment purposes (i.e., a HHA that would receive payment for
all services during a designated EOC). Medicare addressed this problem
through the establishment of an administratively complex on-line
inquiry transaction system [i.e., a Health Insurance Query for Health
Agencies (HIQH)] whereby other home health providers could determine whether
or not the beneficiary was currently in a home health EOC. This
on-line query system required the establishment of a HHA PPS episode
auxiliary file which is continually updated as Requests for Anticipated
Payments (RAPs) and claims are processed through the Regional Home
Health Intermediary’s (RHHI) claims processing systems. The HIQH
system must be able to immediately return the following information
to providers querying the system: 1) contractor and provider numbers;
2) episode start and end dates; 3) period status indicator; 4) HHA
benefit periods; 5) secondary payer information; 6) hospice periods;
and 7) HIQH header information. The HIQH transaction system must also
be able to access 36 episode iterations displayed two at a time.
3.1.2 The implementation
and maintenance of such an on-line transactional query system would be
administratively burdensome and costly for the TRICARE Program.
It would have to be maintained by one of the claims processing subcontractors
since it is a national system requiring continual on-line updating.
Determining “primary” provider status from the query system (i.e.,
the first RAP or, under special circumstances, the first claim submitted
and processed by the RHHI) would circumvent the contractors’ utilization
management responsibilities/requirements under their existing Managed
Care Support (MCS) contracts. In other words, the contractors would
no longer be able to assess and direct Home Health Care (HHC) within
their region(s). Designation of primary HHA status (i.e., the only
HHA allowed to receive payment for services rendered during an EOC)
would be dependent on the first RAP or claim submitted and processed
for a particular EOC. The determination of where and by whom the services
are provided would be dependent on the provider instead of the contractor.
3.1.3 An alternative
approach is being adopted that will meet the primary goals of ensuring Medicare
PPS payment rates and benefit coverage while retaining utilization
management. Under this alternative approach, the preauthorization
process shall determine “primary status” of the HHA. Authorization
screens (part of the automated authorization file) shall be used
to house pertinent episode data. This alternative shall necessitate
contractor preauthorization for all HHC (i.e., all beneficiary categories).
The alternative authorization process is preferable to the development
and maintenance of a national on-line transactional query system,
given its enormous implementing and maintenance costs. Adoption
of the above alternative will preclude implementation of Medicare’s
on-line transactional system and maintenance of complex auxiliary
episode files. However, adoption of this alternative process does
not preclude the prescribed conventions currently in place for establishing EOCs;
e.g., transfers, discharges and readmissions to the same facility
within 60-day episodes, Significant Changes In Condition (SCICs),
Low Utilization Payment Adjustments (LUPAs), and continuous EOCs
will all be monitored and authorized as part of the authorization
process. Contractors shall maintain and update episode data on expanded
authorization screens.
3.2 Designation of Primary Provider
3.2.1 Preauthorization
Process
The preauthorization process is critical
to establishment of primary provider status under the HHA PPS; i.e.,
designating that HHA which may receive payment under the CB provisions
for home health services provided under a Plan of Care (POC).
3.2.1.1 The contractor
is responsible for coordinating referral functions for all Military
Health System (MHS) beneficiaries seeking HHC. In other words, HHC
can only be accessed by TRICARE Program beneficiaries upon referral
by the PCM, or attending physician, and with preauthorization by the
contractor. The contractor shall establish and maintain these functions
to facilitate referrals of beneficiaries to HHAs. For example, a
beneficiary in need of home health services will request preauthorization
and placement by the contractor or other contractor designee. The
contractor shall search its network for a HHA which will meet the
needs of the requesting beneficiary. The beneficiary will be granted
preauthorization approval for home health services provided by the
selected HHA. The selected HHA will in turn be notified of its primary
provider status under the TRICARE Program (i.e., the selected HHA
shall be notified that it will be the only HHA authorized for payment
for services provided to the referred TRICARE Program beneficiary)
and must submit a request for anticipated payment after the first
service has been rendered. The RAP will initiate the EOC under the
preauthorization process.
3.2.1.2 The preauthorization
process shall extend to all intervening events occurring during
the episode period (e.g., preauthorization is required for transfers
to another HHA and readmission to the same HHA within 60 days of
previous discharge). In each case, the contractor shall maintain responsibility
for designating primary provider status under the HHA PPS.
3.2.2 Data Requirement/Maintenance
The tax identification number (9-18 positions)
of the designated primary provider (HHA) shall be maintained and
updated on the automated authorization file (i.e., the authorization
screen).
3.3 Opening and Length of HHA
PPS Episode.
While the authorization process
will take the place of the HIQH in designation of primary provider
status and maintenance and updating of pertinent episode data, it
will not preclude the following conventions for reporting and payment
of HHA EOCs:
3.3.1 In most cases, an HHA PPS episode will be opened
by the receipt of a RAP, even if the RAP or claim has zero reimbursement.
The contractor will have already notified the selected HHA of its
primary status for billing under the consolidated standards prior
to submission of the RAP. The preauthorization requirement will
negate the need for a query system (i.e., the need for keeping other
home health providers informed of whether a beneficiary is already
under the care of another HHA), since providers shall be keenly
aware of this requirement for primary status under the TRICARE Program.
In other words, if an HHA has not received prior notification from
the contractor of its selection for treatment of a TRICARE Program
beneficiary, it does not have primary provider status under the
Program.
3.3.2 Claims, as opposed to RAPs, will only open
episodes in one special circumstance: when a provider knows from
the outset that four or fewer visits will be provided for the entire
episode, which always results in a LUPA, and therefore decides to
forego the RAP so as to avoid recoupment of the difference of the
large initial percentage episode payment and the visit-based payment.
This particular billing situation exception is referred to as a
No-RAP LUPA.
3.3.3 Multiple episodes can be opened for the same
beneficiary at the same time. The same HHA may require multiple
episodes to be opened for the same beneficiary because of an unexpected readmission
after discharge, or if for some reason a subsequent episode RAP
is received prior to the claim for the previous episode. Multiple
episodes may also occur between different providers if a transfer
situation exists. Again, however, the contractors shall always be
aware of the intervening events (e.g., transfers to another HHAs
or discharge and readmission to the same facility during the same
60-day EOC) due to ongoing utilization review and preauthorization
requirements under contractors’ managed care systems. The contractor
shall be responsible for designating primary provider status whether
it be for a new provider, in the case of transfer, or readmission
to the same provider during a 60-day EOC. The contractors’ system
shall post RAPs received with appropriate transfer and re-admit
indicators to facilitate the creation of multiple episodes. Same-day
transfers are permitted, such that an episode for one agency, based
on the claim submitted by the agency, can end the same date as an
episode was opened by another agency for the same beneficiary, assuming preauthorization
has been initiated and granted by the contractor.
3.3.4 When episodes
are created from RAPs, the system calculates a period end date that
does not exceed the start plus 59 days. The system shall assure
no episode exceeds this length under any circumstance, and will
auto-adjust the period end date to shorten the episode if needed
based on activity at the end of the episode (i.e., shortened by
transfer).
3.3.5 The system shall reject RAPs and claims with
statement dates overlapping existing episodes, including No-RAP
LUPA claims, unless a transfer or discharge and re-admit situation
is indicated. The system shall also reject claims in which the dates
of the visits reported for the episode do not fall within the episode
period established by the same agency. Sixty day episodes, starting
on the original period start date, shall remain on record in these
cases.
3.3.6 The system shall auto-cancel claims, and adjust
episode lengths, when episodes are shortened due to receipt of other
RAPs or claims indicating transfer or readmission. The auto-adjusted episode
shall default to end the day before the first date of service of
the new RAP or claim causing the adjustment, even though the episode
length may change once claims finalizing episodes are received. Payment
for the episode is automatically adjusted [a Partial Episode Payment
(PEP) adjustment] without necessitating re-billing by the HHA. If,
when performing such adjustments, there is no claim in paid status
for the previous episode that will receive the PEP adjustment, the
system shall adjust the period end date; however, if the previous
claim is in paid status, both the claim and the episode will be adjusted.
3.3.7 In a PEP
situation, if the first episode claim contains visits with dates
in the subsequent episode period, the claim of the first episode
shall be rejected by the system with a reject code that indicates
the date of the first overlapping visit. The claim rejected by the
system shall then be returned to the HHA by the contractor for correction.
If the situation is also a transfer, when the first HHA with the adjusted
episode subsequently receives a rejected claim, the agency can either
re-bill by correcting the dates, or seek payment under arrangement
from the subsequent HHA. For readmission and discharge, the agency
may correct the erroneously billed dates for its own previously-submitted
episode, but corrections and adjustments in payment shall be made
automatically as appropriate whether the HHA submits corrections
or not.
3.3.8 If the from dates on two simultaneously received
RAPs, or No-RAP LUPA claims, overlap, the system shall reject the
one for which there is no prior authorization (i.e., the RAP from
the HHA for which there was no designated primary provider status
by the contractor). In such cases, contractors will return the claims
rejected by the system to providers.
3.3.9 If a claim is canceled by
an HHA, the system shall cancel the episode. If an HHA cancels a RAP,
the system shall also cancel the episode. When RAPs or claims are
auto-canceled or canceled by the system, the system shall not cancel
the episode. A contractor may also take an action that results in cancellation
of an episode, usually in cases of fraudulent billing. Other than
cancellation, episodes are closed by final processing of the claim
for that episode.
3.4 Other Editing And Changes
For HHA PPS Episodes
3.4.1 The system shall assure that the final from
date on the episode claim equals the calculated period end date
for the episode if the patient status code for the claim indicates
the beneficiary will remain in the care of the same HHA (patient
status code 30).
3.4.2 If the patient dies, represented
by a patient status code of 20, the episode will not receive a PEP
adjustment (i.e., the full payment episode amount will be allotted),
but the through date on the claim will indicate the date of death
instead of the episode end date.
3.4.3 When the patient status of
a claim is 06, indicating transfer, the episode period end date shall
be adjusted to reflect the through date of that claim, and payment
is also adjusted.
3.4.4 The system shall permit a
“transfer from” and a “transfer to” agency to bill for the same
day when it is the date of transfer and a separate RAP/claim is
received overlapping that 60-day period containing either a transfer
or a discharge-readmit indicator.
3.4.5 When the status of the claim
is 01, no change is made in the episode length or claim payment
unless a separate RAP/Claim is received overlapping that 60-day
period and containing either a transfer or a discharge-readmit indicator.
3.4.6 The system
shall also act on point of origin codes
on RAPs; for example, “B” (indicating transfer) and “C” (indicating
readmission after discharge by the same agency in the same 60-day period)
will open new episodes. In addition to these two codes, though,
any approved point of origin code may
appear, and these other codes alone will not trigger creation of
a new episode.
3.4.7 Claims for institutional inpatient
services [i.e., inpatient hospital and Skilled Nursing Facility (SNF)
services] will continue to have priority over claims for home health
services under HHA PPS. Beneficiaries cannot be institutionalized
and receive homebound care simultaneously. Therefore, if an HHA
PPS claim is received, and the system finds dates of service on
the HH claims that fall within the dates of an inpatient or SNF
claim (not including the dates of admission and discharge), the
system will reject the HH claim.
3.4.8 A beneficiary does not have
to be discharged from home care because of an inpatient admission.
If an agency chooses not to discharge and the patient returns to
the agency in the same 60-day period, the same episode continues,
although a SCIC adjustment is likely to apply. Occurrence span code
74, previously used in such situations, should not be employed on
HHA PPS claims.
3.4.9 If an agency chooses to discharge,
based on an expectation that the beneficiary will not return, the
agency should recognize that if the beneficiary does return to them
in the same 60-day period, there would be one shortened HHA PPS
episode completed before the inpatient stay ending with the discharge,
and another starting after the inpatient stay, with delivery of
home care never overlapping the inpatient stay. The first shortened
episode would receive a PEP adjustment only because the beneficiary
was receiving more home care in the same 60-day period. This would
likely reduce the agency’s payment overall. The agency should cancel
the PEP claim and the readmission RAP in these cases and re-bill
a continuous EOC.
3.4.10 The system
shall edit to prevent duplicate billing of Durable Equipment (DE)
and Durable Medical Equipment (DME). Consequently, the system must
edit to ensure that all DME items billed by HHAs have a line-item
date of service and Healthcare Common Procedure Coding System (HCPCS) coding,
though home health CB does not apply to DME by law.
3.5 Chart Summarizing
the Effects of RAP/Claim Actions on the HHA PPS Episode
|
Transaction
|
How System
Is Impacted
|
How Other
Providers Are Impacted
|
|
Initial
RAP (Percentage Payments 0-60)
|
Open
an episode record using RAP’s “from” date; “through” date is automatically
calculated to extend through 60th day.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
|
|
Subsequent
Episode RAP
|
Opens
another subsequent episode using RAP’s “from” date; “through” date
is automatically calculated to extend through next episode.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
|
|
Initial
RAP with Transfer Origin Code of B
|
Opens
an episode record using RAP’s “from” date; “through” date is automatically
calculated to extend through 60th day.
|
• The period end date on the RAP of the
HHA the beneficiary is transferring from is automatically changed
to reflect the day before the from date on the RAP submitted by
the HHA the beneficiary is transferring to. The HHA the beneficiary
is transferring from cannot bill for services past the date of the transfer.
• Another HHA cannot bill during this
episode unless another transfer situation occurs.
|
|
RAP
Cancellation by Provider or Contractor
|
The
episode record is deleted from system.
|
• No episode exists to prevent RAP submission
or No-RAP LUPA claim submission.
|
|
RAP
Cancellation by System
|
The
episode record remains open on system
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
• To correct information on this RAP,
the original RAP must be replaced, canceled by the HHA and then
re-submitted once more with the correct information.
|
|
Claim
(full)
|
60-day
episode record completed; episode “through” date remains at the
60th day; Date of Latest Billing Action (DOLBA) updates with date
of last service.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
|
|
Claim
(discharge with goals met prior to Day 60)
|
Episode
record complete; episode “through” date remains at the 60th day;
DOLBA updates with date of last service.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
|
|
Claim
(transfer)
|
Episode
completed; episode period end date reflects transfer; DOLBA updates
with date of last service
|
• A RAP or No-RAP LUPA claim will be accepted
if the “from” date is on or after episode “through” date.
|
|
No-RAP
LUPA Claim
|
Opens
an episode record using claim’s “from” date; the “through” date
automatically calculated to extend through 60th day; DOLBA updates
with date of last service.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• Other No-RAP LUPA claims will be rejected
unless a transfer source is present.
• Because a RAP is not submitted in this
situation until the No-RAP LUPA claim is submitted, another provider
can open an episode by submitting a RAP or by submitting a No-RAP
LUPA Claim.
|
|
Claim
(adjustment)
|
No
impact on the episode unless adjustment changes patient status to
transfer.
|
• No impact
|
|
Claim
Cancellation by Provider or Contractor
|
The
episode is deleted from system.
|
• No episode exists to prevent RAP submission
or No-RAP LUPA claim submission.
|
|
Claim
Cancellation by System
|
The
episode record remains open on system.
|
• Other RAPs submitted during this open
episode will be rejected unless a transfer source code is present.
• No-RAP LUPA claims will be rejected
unless a transfer source code is present.
|
3.6 Episode Data Requirement
The contractor’s authorization screen (part
of its automated authorization file) shall show whether or not the
beneficiary is currently in a home health EOC (being served by a
primary HHA), along with the following information:
3.6.1 The beneficiary’s
name and sex.
3.6.2 Pertinent contractor and provider
number.
3.6.3 Period Start and End Dates. The start date
is received on a RAP or claim, and the end date is initially calculated
to be the 60th day after the start date, changed as necessary when
the claim for the episode is finalized.
3.6.4 Date of Earliest Billing Action
(DOEBA) and DOLBA. Dates of earliest and latest billing activity.
3.6.5 Period
Status Indicator. The patient status code on HHA PPS claim, indicating
the status of the HH patient at the end of the period.
3.6.6 Transfer/Readmit
Indicator. Point of origin codes taken
from the RAP or claim as an indicator of the type of admission (transfer,
readmission after discharge).
3.6.7 The Health Insurance PPS (HIPPS)
Code(s). Up to six for any episode, representing the basis of payment
for episodes other than those receiving a LUPA.
3.6.8 Principle
Diagnosis Code and First Other Diagnosis Code. From the RAP or overlaying
claim.
3.6.9 A LUPA Indicator. Received from the system
indicating whether or not there was a LUPA episode; and
3.6.10 At least
six of the most recent episodes for any beneficiary.