|
Admission Date
|
For HHA PPS,
date of first service of episode or first service in a period of
continuous care (multiple episodes) placed in Form Locator (FL)
12 of the CMS 1450 UB-04 found in the TRICARE Program and/or National
Uniform Billing Committee (NUBC) manuals. Centers for Medicare and
Medicaid Services (CMS) manuals can be found on the CMS web site
( https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html). |
|
Claim
|
Second of two
“bookends” at opening and closing of HHA PPS episode to receive
one of two split percentage payments.
|
|
CMS
|
The Centers
for Medicare and Medicaid Services and the federal portions of Medicaid
and the Child Health Program.
|
|
CMS 1450
|
CMS’s version
of the CMS 1450 UB-04.
|
|
CMS 1500
|
The Claim form,
in either paper or electronic version (NSF), used by most non-institutional
health care providers and suppliers to bill the TRICARE Program.
Published as CMS 1500 Claim Form.
|
|
DME
|
Durable Medical
Equipment. Billed by revenue codes and/or HCPCs. Paid by CMS according
to CMS DME fee schedule accessible on the HCFA web site ( https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html?redirect=/center/dme.asp). |
|
Episode
|
60-day unit
of payment for HHA PPS.
|
|
Grouper
|
A software module
that “groups” information for payment classification; for HHA PPS,
data from the OASIS assessment tool is grouped to form Gars and
output HIPPS codes. Specifications for the HHA PPS Grouper are posted
on the HCFA web site ( https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html),
and the Grouper module is also built into PPS-compatible versions
of HAVEN software automating the OASIS assessment tool. |
|
HCFA
|
The HCFA, the
federal agency administering the TRICARE program and the federal
portions of Medicaid and the Child Health Program.
|
|
HCPCS Code(s)
|
Healthcare Common
Procedural Coding System. Coding for services or items used on the
CMS 1450 UB-04 in FL 44 or CMS 1500 Claim Forms. A list of HCPCS
is accessible on the web site ( https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html). |
|
HHA
|
Home Health
Agency(ies)
|
|
(H)HRG
|
Home Health
Resource Group. One of 80 home health episode payment rates.
|
|
HIPPS
|
Health Insurance
Prospective Payment System. Procedural coding used in FL 44 of the
CMS 1450 UB-04 in association with certain CMS prospective payment
systems (Skilled Nursing Facility (SNF), home health). Eight HIPPS
are assigned to each of the HHRGs for HHA PPS.
|
|
Inquiry System (HIQH)
|
An on-line
transaction system providing information on HHA PPS episodes for
specific TRICARE Program beneficiaries for HHAs and hospices. Like
the current HIQA eligibility inquiry system, this system will be
based on batch claim data available in the Common Working File,
a component of TRICARE contractors’ claims processing system, available
to providers via their contractors.
|
|
Line Item
|
Service or item-specific
detail of claim. Contains repeated entries of FLs 42-48 on CMS 1450
UB-04.
|
|
LUPA
|
Low Utilization
Payment Adjustment. An episode of 4 or less visits paid by national
standardized per visit rates instead of HHRGs.
|
|
National Standard
Per Visit Rates
|
National rates
for each of the 6 home health disciplines based on historical claims
data. Used in payment of LUPAs and calculation of outliers.
|
|
No-RAP LUPAs
|
A billing
scenario in which only a claim, not a RAP, is submitted for an episode
by an HHA because the HHA is aware from the outset that the episode
will be four visits or less.
|
|
OASIS
|
Outcome Assessment
Information Set. The home health assessment instrument required
by CMS.
|
|
Outlier
|
An addition
to a full episode payment in cases where costs of services delivered
are estimated to exceed a fixed loss threshold. HHA PPS outliers
are computed as part of the TRICARE Program claims payment by Pricer
for all non-LUPA episodes.
|
|
Patient Status
Code
|
FL 17 of the
CMS 1450 UB-04 describing patient status at discharge/end of period;
of note for HHA PPS in the code list filling this location: “01”
= “discharge to home/self”, “06” = “discharged/transferred home/HHA
care” and “30” = “still a patient”).
|
|
PEP
|
Partial Episode
Payment (adjustment). A reduced episode payment that may be made
based on the number of service days in an episode (always less than
60 days, employed in cases of transfers or discharge with readmissions).
|
|
POC
|
Plan of care.
The TRICARE Program home health services for homebound beneficiaries
must have a physician-established plan (see 485 below).
|
|
P/O(S)
|
Prosthetics
and orthotics
|
|
PPS
|
Prospective
Payment System. TRICARE Program payment for medical care based on
pre-determined payment rates or periods, linked to the anticipated
intensity of services delivered and/or beneficiary condition.
|
|
Pricer
|
Software modules
in TRICARE contractors’ claims processing systems, specific to certain
benefits, used in pricing claims, most often under prospective payment
systems.
|
|
RAP
|
Request for
Anticipated Payment. First of two “bookends” at opening and closing
of HHA PPS episode to receive one or two split percentage payments.
Note: although the RAP uses a CMS 1450 UB-04, it is not a claim
according to the TRICARE Program statutes, and is not subject to
the payment floor, among other differences from claims.
|
|
Revenue Code
|
Payment
codes for services or items placed in FL 42 of the CMS 1450 UB-04.
Note that a new revenue code 023 will be used on a distinct line
item when billing episode payments (HIPPS in HCPCs field, separate
line items for visits and supplies follow on claim); an “x” in the
last digit of three digit revenue codes means that value can vary
from 0-9.
|
|
RHHI
|
Regional Home
Health Intermediary. Five (5) fiscal intermediaries nationally designated
to process TRICARE Program home health and hospice claims.
|
|
SCIC
|
Significant
Change in Condition (adjustment). When changes in patient condition
dictate, a single episode may be paid under multiple HHRGs, the
amount for each HHRG pro-rated to the number of service days delivered
under the HHRG, and all pro-rated amounts added for the final episode payment.
|
|
Point
of Origin Code
|
FL 15 of the
CMS 1450 UB-04; of note are new codes for HHA PPS: “B” = “transfer
from another home health facility”, and “C” = “readmission to the
same HHA”.
|
|
TOB
|
Type of Bill
(i.e., 032x, 034x). Coding representing the nature of each CMS 1450
UB-04 claim (i.e., type of benefit, such as homebound home health;
payment source, such as specific TRICARE trust fund; and frequency
of bill, such as initial or cancellation) -- and “x” in the last
digit of numeric three digit type of bill means that value can be
from 0-9.
|
|
UB-92
|
The claim or
bill form, in either paper or electronic version, used by most institutional
health care providers. Published by CMS as the CMS 1450 UB-04, but
the standard itself is maintained by a non-governmental body: the
NUBC.
|
|
485
|
CMS form number
for Plan of Care (see POC above).
|