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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Home Health Care (HHC)
Chapter 12
Addendum P
Examples Of Claims Submission Under Home Health Agency Prospective Payment System (HHA PPS)
Revision:  C-31, January 31, 2019
Due to the size of Figure 12.P-1, please go to the next page.
Figure 12.P-1  Request for Anticipated Payment (RAP) - Non-Transfer Situation
Description of Figure 7.B-1 (Page 1 of 3) - A picture of TRICARE Management Activity Form 771 (TMA 771), June 1991, Instructions for Submitting Reimbursement Information for Psychiatric Residential Treatment Centers Serving Children and Adolescents
Figure 12.P-2  RAP - Non-Transfer Situation With Line Item Service Added
This is an example of what a RAP might look like if other line item data had to be added because your software required a total charge greater than zero on the CMS 1450 UB-04. The system will look only at the HIPPS code information in order to generate payment. Remember that you will also need to enter this line item data on the claim. That is, in this example, your claim would also contain the charge for the Skilled Nursing visit on October 1, 2000.