TRICARE Reimbursement Manual 6010.61-M, April 1, 2015 Chapter 12 Home Health Care (HHC) Revision: C-37, June 18, 2019 Section/Addendum Subject/Addendum Title 1 Home Health Benefit Coverage And Reimbursement - General Overview 2 Home Health Care (HHC) - Benefits And Conditions For Coverage Figure 12.2-1 Copayments/Cost-Shares For Services Reimbursed Outside The HHA PPS When Receiving Home Health Services Under A POC For Services Rreceived Before January 1, 2018 3 Home Health Benefit Coverage And Reimbursement - Assessment Process 4 Home Health Benefit Coverage And Reimbursement - Prospective Payment Methodology Figure 12.4-1 Calculating Domain Scores From Response Values Figure 12.4-2 Clinical Severity Domain Figure 12.4-3 Functional Status Domain Figure 12.4-4 Service Utilization Domain Figure 12.4-5 HHRG To HIPPS Code Crosswalk Figure 12.4-6 New HIPPS Code Structure Under HH PPS Case-Mix Refinement Figure 12.4-7 Scoring Matrix For Constructing HIPPS Code Figure 12.4-8 Case-Mix Adjustment Variables And Scores For Episodes Ending Before January 1, 2012 Figure 12.4-9 Case-Mix Adjustment Variables And Scores For Episodes Ending On Or After January 1, 2012 Figure 12.4-10 Relative Weights For NRS - Six-Group Approach Figure 12.4-11 NRS Case-Mix Adjustment Variables And Scores Figure 12.4-12 Format For Treatment Authorization Code Figure 12.4-13 Converting Point Values To Letter Codes Figure 12.4-14 Example Of A Treatment Authorization Code Figure 12.4-15 Calculation Of National 60-day Episode Payment Amounts Figure 12.4-16 Standardization For Case-Mix And Wage Index Figure 12.4-17 Per Visit Payment Amounts For Low-Utilization Payment Adjustments 5 Home Health Benefit Coverage And Reimbursement - Primary Provider Status And Episodes Of Care (EOCs) 6 Home Health Benefit Coverage And Reimbursement - Claims And Billing Submission Under Home Health Agency Prospective Payment System (HHA PPS) 7 Home Health Benefit Coverage And Reimbursement - Pricer Requirements And Logic 8 Home Health Benefit Coverage And Reimbursement - Medical Review Requirements A Definitions And Acronym Table B Home Health Consolidated Billing Code List - Non-Routine Supply (NRS) Codes C Home Health Consolidated Billing Code List - Therapy Codes D Home Health Certification And Plan Of Care (POC) E Primary Components Of A Home Care Patient Assessment F Outcome and Assessment Information Set (OASIS) Items Used For Assessments Of 60-Day Episodes G Diagnosis Codes For Home Health Resource Group (HHRG) Assignment H Home Health Resource Group (HHRG) Worksheet Figure 2.H-1 HHRG For Episodes Beginning On Or After January 1, 2008 Figure 2.H-2 Abbreviated OASIS Questions I Health Insurance Prospective Payment System (HIPPS) Tables For Pricer J Home Assessment Validation and Entry (HAVEN) Reference Manual K (CY 2017) Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2017 Figure 12.K.2017-1 CY 2017 National Standardized 60-Day Episode Payment Amounts Figure 12.K.2017-2 CY 2017 National Per-Visit Payment Amounts For HHAs Figure 12.K.2017-3 CY 2017 NRS Conversion Factor Figure 12.K.2017-4 CY 2017 Relative Weights For The Six-Severity NRS System Figure 12.K.2017-5 CY 2017 Cost-Per-Unit Payment Rates For The Calculation Of Outlier Payments Figure 12.K.2017-6 CY 2017 Per-Visit Amounts For Services Provided In A Rural Area Figure 12.K.2017-7 CY 2017 Relative Weights For The Six-Severity NRS System For Beneficiaries Residing In A Rural Area K (CY 2018) Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2018 Figure 12.K.2018-1 CY 2018 National Standardized 60-Day Episode Payment Amounts Figure 12.K.2018-2 CY 2018 National Per-Visit Payment Amounts For HHAs Figure 12.K.2018-3 CY 2018 NRS Conversion Factor Figure 12.K.2018-4 CY 2018 Relative Weights For The Six-Severity NRS System Figure 12.K.2018-5 CY 2018 Cost-Per-Unit Payment Rates For The Calculation Of Outlier Payments Figure 12.K.2018-6 CY 2018 Per-Visit Amounts For Services Provided In A Rural Area Figure 12.K.2018-7 CY 2018 Relative Weights For The Six-Severity NRS System For Beneficiaries Residing In A Rural Area Figure 12.K.2018-8 CY 2018 Cost-Per-Unit Payment Rates For The Calculation of Outlier Payments IN A Rural Area K (CY 2019) Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2019 Figure 12.K.2019-1 CY 2019 National Standardized 60-Day Episode Payment Amounts Figure 12.K.2019-2 CY 2019 National Per-Visit Payment Amounts For HHAs Figure 12.K.2019-3 CY 2019 NRS Conversion Factor Figure 12.K.2019-4 CY 2019 Relative Weights For The Six-Severity NRS System Figure 12.K.2019-5 CY 2019 Cost-Per-Unit Payment Rates For The Calculation Of Outlier Payments Figure 12.K.2019-6 CY 2019 Rural Add-On Percentages By Category L Annual Home Health Agency Prospective Payment System (HHA PPS) Wage Index Updates M Diagnoses Associated With Each Of The Diagnostic Categories Used In Case-Mix Scoring N Diagnoses Included In The Diagnostic Categories Used For The Non-Routine Supplies (NRS) Case-Mix Adjustment Model O Code Table For Converting Julian Dates To Two Position Alphabetic Values P Examples Of Claims Submission Under Home Health Agency Prospective Payment System (HHA PPS) Figure 12.P-1 Request for Anticipated Payment (RAP) - Non-Transfer Situation Figure 12.P-2 RAP - Non-Transfer Situation With Line Item Service Added Figure 12.P-3 RAP - Transfer Situation Figure 12.P-4 RAP - Discharge/Re-Admit Figure 12.P-5 RAP - Cancellation Figure 12.P-6 Claim - Non-Transfer Situation Figure 12.P-7 Claim - Transfer Situation - Beneficiary Transfers To Your HHA Figure 12.P-8 Claim - Significant Change in Condition (SCIC) Situation Figure 12.P-9 Claim - No-RAP-Low Utilization Payment Adjustment (LUPA) Claim Figure 12.P-10 Claim Adjustment Figure 12.P-11 Claim - Cancellation