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Admission Date
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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 website ( https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html). |
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Claim
|
Second of two “bookends” at
opening and closing of HHA PPS episode to receive one of two split
percentage payments.
|
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CMS
|
The Centers for Medicare and
Medicaid Services and the federal portions of Medicaid and the Child
Health Program.
|
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CMS 1450
|
CMS’s version of the CMS 1450
UB-04.
|
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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.
|
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DME
|
Durable Medical Equipment.
Billed by revenue codes and/or HCPCs. Paid by CMS according to CMS
DME fee schedule accessible on the HCFA website ( https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html?redirect=/center/dme.asp). |
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Episode
|
60-day unit of payment for
HHA PPS.
|
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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 website
( 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 website ( 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.
|
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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 four or less visits paid by national standardized
per visit rates instead of HHRGs.
|
|
National Standard Per Visit
Rates
|
National rates for each of
the six 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.
|
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OASIS
|
Outcome Assessment Information
Set. The home health assessment instrument required by CMS.
|
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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.
|
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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).
|
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POC
|
Plan of care. The TRICARE Program
home health services for homebound beneficiaries must have a physician-established
plan (see 485 below).
|
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P/O(S)
|
Prosthetics and orthotics
|
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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.
|
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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 (FIs)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
prorated to the number of service days delivered under the HHRG,
and all prorated 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.
|
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485
|
CMS form number for Plan of
Care (see POC above).
|