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
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.
Figure 12.P-3 RAP - Transfer Situation
Note: Point of Origin [Form
Locator (FL) 15] is a B, which indicates that this beneficiary transferred to
your HHA from another HHA.
Figure 12.P-4 RAP - Discharge/Re-Admit
Note: Point of Origin (FL
15) is a C, which indicates that this beneficiary was discharged
from your HHA, but was readmitted within the same 60-day episode.
Figure 12.P-5 RAP - Cancellation
Note: The Type of Bill (TOB) changes to end in an 8,
a Claim Change Reason Code (e.g., D5) is included, and the RHHI’s
Internal Control Number (ICN) that identified the original RAP is
included.
Figure 12.P-6 Claim - Non-Transfer Situation
Figure 12.P-7 Claim - Transfer Situation -
Beneficiary Transfers To Your HHA
Note: Point of Origin (FL
15) is a B, which indicates that this beneficiary transferred to
your HHA from another HHA.
Figure 12.P-8 Claim - Significant Change in
Condition (SCIC) Situation
Note: Two HIPPS Codes appear on this claim due to a
SCIC.
Figure 12.P-9 Claim - No-RAP-Low Utilization
Payment Adjustment (LUPA) Claim
In this example, the beneficiary transferred
to another HHA. Your HHA provided two services and had not yet submitted
the RAP when the beneficiary transferred; therefore, you have a
No-RAP-LUPA Claim situation.