3.2.3.4 Some new subsystems will be
created and others modified to mesh with existing claims processing
systems.
3.2.3.4.1 The
contractor’s authorization process (including data entering screens)
will be used in designating primary provider status and maintaining
and updating the episode/period of care information/history of each
beneficiary. The managed care authorization system will be used
in lieu of Medicare’s remote access inquiry system [Health Insurance
Query for HHAs (HIQH)]. The data requirements for tracking beneficiary
episodes/periods of care over time are found in
Section 5.
3.2.3.4.2 Home Health Resource Groups
(HHRGs) for claims will be determined at HHAs by inputting OASIS
data (OASIS is the clinical data set that currently must be completed
by HHAs for patient assessment) into a Home Assessment Validation
and Entry (HAVEN) System. The HAVEN software package contains a
Grouper module that will generate a HHRG for a particular 60-day
episode or 30-day period of care based upon the beneficiary’s condition,
functional status and expected resource consumption. Updated versions
of this software package may be downloaded from the CMS web site.
An abbreviated assessment will be conducted for eligible TRICARE
beneficiaries who are under the age of eighteen or receiving maternity
care from a Medicare certified HHA. This will require the manual
completion and scoring of a HHRG Worksheet for pricing and payment
under the HHA PPS. OASIS assessments are not required for authorized
care in non-Medicare certified HHAs that qualify for corporate services
provider status under TRICARE (i.e., HHAs which have not sought
Medicare certification due to the specialized beneficiary categories
they service, such as patients receiving maternity care and beneficiaries
under the age of 18).
3.2.3.4.3 All HHA PPS claims will run
through Pricer software, which, in addition to pricing Health Insurance
Prospective Payment System (HIPPS) codes for HHRGs, will maintain
six national standard visit and unit rates to be used in outlier
and Low Utilization Payment Adjustment (LUPA) determinations.
3.2.3.4.4 Episodes/periods of care paid
under HHA PPS will be restricted to homebound beneficiaries under
existing POCs; i.e., CMS 1450 UB-04 TOB 032X and 033X. However,
034X bills will be used by HHAs for services not bundled into HHA
PPS rates.
3.2.3.4.5 Requests for Anticipated Payment
(RAP) will be submitted using TOB 0322 only.
3.2.3.4.6 The claim for an episode/period
of care (TOB 0329) will be processed in the claims processing system
as an adjustment to the RAP triggering full or final episode/period
of care payment, so that the claim will become the single adjusted
or finalized claim for an episode/period of care in claims history
-- claims will be able to be adjusted by HHAs after submission.
3.2.3.4.7 There shall not be late charge
bills (TOB 0325 or 0335) under HHA PPS -- services can only be added
through adjustment of the claim (TOB 0327 or 0337).
3.2.3.4.8 New codes will appear on standard
formats under HHA PPS.
3.2.3.4.9 The TOB frequency code of “9”
has been created specifically for HHA PPS billing.
3.2.3.4.10 A 0023 revenue code will appear
on both RAPs and claims, with new HIPPS codes for HHRGs in the Healthcare
Common Procedure Codes (HCPCs) field of a line item.
3.2.3.4.11 Point of Origin codes B (transfer
from another HHA) and C (discharge and readmission to
the same HHA) have been created for HHA PPS billing.