3.0 POLICY
3.1 Background
3.1.1 With the advent of the HHA
PPS and home health Consolidated Billing (CB), Medicare had to establish
a means of identifying a “primary” HHA for payment purposes (i.e.,
a HHA that would receive payment for all services during a designated episode/period).
Medicare addressed this problem through the establishment of an
administratively complex on-line inquiry transaction system [i.e.,
a Health Insurance Query for Health Agencies (HIQH)] whereby other
home health providers could determine whether or not the beneficiary
was currently in a home health episode/period of care.
This on-line query system required the establishment of a HHA PPS
episode/period auxiliary file which
is continually updated as Requests for Anticipated Payments (RAPs)
and claims are processed through the Regional Home Health Intermediary’s
(RHHI) claims processing systems. The HIQH system must be able to
immediately return the following information to providers querying
the system: 1) contractor and provider numbers; 2) episode/period start
and end dates; 3) period status indicator; 4) HHA benefit periods;
5) secondary payer information; 6) hospice periods; and 7) HIQH
header information. The HIQH transaction system must also be able
to access 36 episode/period iterations
displayed two at a time.
3.1.2 The implementation
and maintenance of such an on-line transactional query system would be
administratively burdensome and costly for the TRICARE Program.
It would have to be maintained by one of the claims processing subcontractors
since it is a national system requiring continual on-line updating.
Determining “primary” provider status from the query system (i.e.,
the first RAP or, under special circumstances, the first claim submitted
and processed by the RHHI) would circumvent the contractors’ utilization
management responsibilities/requirements under their existing Managed
Care Support (MCS) contracts. In other words, the contractors would
no longer be able to assess and direct Home Health Care (HHC) within
their region(s). Designation of primary HHA status (i.e., the only
HHA allowed to receive payment for services rendered during an episode/period
of care) would be dependent on the first RAP or claim
submitted and processed for a particular episode/period
of care. The determination of where and by whom the
services are provided would be dependent on the provider instead
of the contractor.
3.1.3 An alternative
approach is being adopted that will meet the primary goals of ensuring Medicare
PPS payment rates and benefit coverage while retaining utilization
management. Under this alternative approach, the preauthorization
process shall determine “primary status” of the HHA. Authorization
screens (part of the automated authorization file) shall be used
to house pertinent episode/period of care data.
This alternative shall necessitate contractor preauthorization for
all HHC (i.e., all beneficiary categories). The alternative authorization
process is preferable to the development and maintenance of a national
on-line transactional query system, given its enormous implementing and
maintenance costs. Adoption of the above alternative will preclude
implementation of Medicare’s on-line transactional system and maintenance
of complex auxiliary episode/period files.
However, adoption of this alternative process does not preclude
the prescribed conventions currently in place for establishing episodes/periods
of care; e.g., transfers, discharges and readmissions
to the same facility within 60-day episodes or 30-day
periods, Significant Changes In Condition (SCICs),
Low Utilization Payment Adjustments (LUPAs), and continuous care
shall all be monitored and authorized as part of
the authorization process. Contractors shall maintain and update
episode/period data on expanded authorization
screens.
3.2 Designation of Primary Provider
3.2.1 Preauthorization Process
The preauthorization process
is critical to establishment of primary provider status under the
HHA PPS; i.e., designating that HHA which may receive payment under
the CB provisions for home health services provided under a Plan
of Care (POC).
3.2.1.1 The contractor is responsible
for coordinating referral functions for all Military Health System
(MHS) beneficiaries seeking HHC. In other words, HHC can only be
accessed by TRICARE Program beneficiaries upon referral by the PCM,
or attending physician, and with preauthorization by the contractor.
The contractor shall establish and maintain these functions to facilitate
referrals of beneficiaries to HHAs. For example, a beneficiary in
need of home health services shall request preauthorization
and placement by the contractor or other contractor designee. The
contractor shall search its network for a HHA which will meet the
needs of the requesting beneficiary. The beneficiary shall be
granted preauthorization approval for home health services provided
by the selected HHA. The selected HHA shall in
turn be notified of its primary provider status under the TRICARE
Program (i.e., the selected HHA shall be notified that it is the
only HHA authorized for payment for services provided to the referred
TRICARE Program beneficiary) and shall submit
a request for anticipated payment after the first service has been
rendered. The RAP shall initiate the episode/period
of care under the preauthorization process.
3.2.1.2 The preauthorization process
shall extend to all intervening events occurring during the episode
period (e.g., preauthorization is required for transfers to another
HHA and readmission to the same HHA within 60 days or
30 days of previous discharge). In each case, the
contractor shall maintain responsibility for designating primary
provider status under the HHA PPS.
3.2.2 Data
Requirement/Maintenance
The tax
identification number (9-18 positions) of the designated primary
provider (HHA) shall be maintained and updated on the automated
authorization file (i.e., the authorization screen).
3.3 Opening and Length of HHA PPS
Episode
/PeriodWhile the authorization process
will take the place of the HIQH in designation of primary provider status
and maintenance and updating of pertinent episode/period data,
it will not preclude the following conventions for reporting and
payment of HHA episodes/periods of care:
3.3.1 In most cases, an HHA PPS episode/period
shall be opened by the receipt of a RAP, even if the
RAP or claim has zero reimbursement. The contractor shall have
already notified the selected HHA of its primary status for billing
under the consolidated standards prior to submission of the RAP.
The preauthorization requirement will negate the need for a query
system (i.e., the need for keeping other home health providers informed
of whether a beneficiary is already under the care of another HHA), since
providers shall be keenly aware of this requirement for primary
status under the TRICARE Program. In other words, if an HHA has
not received prior notification from the contractor of its selection
for treatment of a TRICARE Program beneficiary, it does not have
primary provider status under the Program.
3.3.2 Claims,
as opposed to RAPs, shall only open
episodes/periods in one special circumstance: when
a provider knows from the outset that four or fewer visits shall be
provided for the entire episode/period,
which always results in a LUPA, and therefore decides to forego
the RAP so as to avoid recoupment of the difference of the large
initial percentage episode/period payment
and the visit-based payment. This particular billing situation exception
is referred to as a No-RAP LUPA.
3.3.3 Multiple
episodes/periods may be opened for
the same beneficiary at the same time. The same HHA may require
multiple episodes/periods to be opened
for the same beneficiary because of an unexpected readmission after
discharge, or if for some reason a subsequent episode/period RAP
is received prior to the claim for the previous episode/period.
Multiple episodes/periods may also
occur between different providers if a transfer situation exists.
Again, however, the contractors shall always be aware of the intervening
events (e.g., transfers to another HHAs or discharge and readmission
to the same facility during the same 60-day episode
or 30-day period of care) due to ongoing utilization review
and preauthorization requirements under contractors’ managed care
systems. The contractor shall be responsible for designating primary
provider status whether it be for a new provider, in the case of
transfer, or readmission to the same provider during a 60-day episode
or 30-day period of care. The contractors’ system
shall post RAPs received with appropriate transfer and re-admit
indicators to facilitate the creation of multiple episodes/periods.
Same-day transfers are permitted, such that an episode/period for
one agency, based on the claim submitted by the agency, may end
the same date as an episode/period was
opened by another agency for the same beneficiary, assuming preauthorization has
been initiated and granted by the contractor.
3.3.4 When episodes/periods are
created from RAPs, the system calculates a period end date that does
not exceed the start plus 59 days. The system shall assure no episode/period exceeds
this length under any circumstance, and shall auto-adjust
the period end date to shorten the episode/period if needed
based on activity at the end of the episode/period (i.e.,
shortened by transfer).
3.3.5 The system
shall reject RAPs and claims with statement dates overlapping existing episodes/periods,
including No-RAP LUPA claims, unless a transfer or discharge and
re-admit situation is indicated. The system shall also reject claims
in which the dates of the visits reported for the episode/period do
not fall within the episode period established by the same agency.
Sixty-day episodes or
30-day periods of care, starting on the original
period start date, shall remain on record in these cases.
3.3.6 The system shall auto-cancel
claims, and adjust episode/period lengths,
when episodes/periods are shortened
due to receipt of other RAPs or claims indicating transfer or readmission.
The auto-adjusted episode/period shall
default to end the day before the first date of service of the new RAP
or claim causing the adjustment, even though the episode/period length
may change once claims finalizing episodes/periods are
received. Payment for the episode /period
is automatically adjusted [a Partial Episode Payment (PEP) adjustment]
without necessitating re-billing by the HHA. If, when performing
such adjustments, there is no claim in paid status for the previous
episode/period that shall receive
the PEP adjustment, the system shall adjust the period end date;
however, if the previous claim is in paid status, both the claim
and the episode/period shall be adjusted.
3.3.7 In a PEP situation, if the
first episode/period claim contains
visits with dates in the subsequent episode period, the claim of
the first episode/period shall be rejected
by the system with a reject code that indicates the date of the
first overlapping visit. The claim rejected by the system shall then
be returned to the HHA by the contractor for correction. If the
situation is also a transfer, when the first HHA with the adjusted
episode/period subsequently receives
a rejected claim, the agency may either
re-bill by correcting the dates, or seek payment under arrangement
from the subsequent HHA. For readmission and discharge, the agency
may correct the erroneously billed dates for its own previously-submitted
episode/period, but corrections and
adjustments in payment shall be made automatically as appropriate
whether the HHA submits corrections or not.
3.3.8 If the from dates on two simultaneously
received RAPs, or No-RAP LUPA claims, overlap, the system shall
reject the one for which there is no prior authorization (i.e.,
the RAP from the HHA for which there was no designated primary provider
status by the contractor). In such cases, contractors shall return
the claims rejected by the system to providers.
3.3.9 If a claim is canceled by an
HHA, the system shall cancel the episode/period.
If an HHA cancels a RAP, the system shall also cancel the episode/period.
When RAPs or claims are auto-canceled or canceled by the system,
the system shall not cancel the episode/period.
A contractor may also take an action that results in cancellation
of an episode/period, usually in cases
of fraudulent billing. Other than cancellation, episodes/periods are
closed by final processing of the claim for that episode/period.
3.4 Other Editing And Changes For
HHA PPS Episodes
/Periods3.4.1 The system shall assure that
the final from date on the episode/period claim
equals the calculated period end date for the episode/period if
the patient status code for the claim indicates the beneficiary
will remain in the care of the same HHA (patient status code 30).
3.4.2 If the patient dies, represented
by a patient status code of 20, the episode/period
shall not receive a PEP adjustment (i.e., the full
payment episode/period amount shall be
allotted), but the through date on the claim shall indicate
the date of death instead of the episode/period end
date.
3.4.3 When the patient status of
a claim is 06, indicating transfer, the episode period end date shall
be adjusted to reflect the through date of that claim, and payment
is also adjusted.
3.4.4 The system
shall permit a “transfer from” and a “transfer to” agency to bill
for the same day when it is the date of transfer and a separate
RAP/claim is received overlapping that 60-day episode
or 30-day period containing either a transfer or
a discharge-readmit indicator.
3.4.5 When the
status of the claim is 01, no change is made in the episode/period length
or claim payment unless a separate RAP/Claim is received overlapping
that 60-day episode or 30-day period and
containing either a transfer or a discharge-readmit indicator.
3.4.6 The system shall also act on
point of origin codes on RAPs; for example, “B” (indicating transfer)
and “C” (indicating readmission after discharge by the same agency
in the same 60-day period) shall open
new episodes/periods. In addition to
these two codes, though, any approved point of origin code may appear,
and these other codes alone shall not
trigger creation of a new episode/period.
3.4.7 Claims for institutional inpatient
services [i.e., inpatient hospital and Skilled Nursing Facility (SNF)
services] shall continue to have priority
over claims for home health services under HHA PPS. Beneficiaries
cannot be institutionalized and receive homebound care simultaneously.
Therefore, if an HHA PPS claim is received, and the system finds
dates of service on the HH claims that fall within the dates of
an inpatient or SNF claim (not including the dates of admission
and discharge), the system shall reject
the HH claim.
3.4.8 A beneficiary
does not have to be discharged from home care because of an inpatient admission.
If an agency chooses not to discharge and the patient returns to
the agency in the same 60-day period, the same episode/period continues,
although a SCIC adjustment is likely to apply. Occurrence span code
74, previously used in such situations, shall not
be employed on HHA PPS claims.
3.4.9 If an
agency chooses to discharge, based on an expectation that the beneficiary
will not return, the agency should recognize that if the beneficiary
does return to them in the same 60-day period, there shall be
one shortened HHA PPS episode/period completed
before the inpatient stay ending with the discharge, and another
starting after the inpatient stay, with delivery of home care never
overlapping the inpatient stay. The first shortened episode/period
shall receive a PEP adjustment only because the beneficiary
was receiving more home care in the same 60-day episode
or 30-day period. This shall likely
reduce the agency’s payment overall. The agency shall cancel
the PEP claim and the readmission RAP in these cases and re-bill
a continuous episode/period of care.
3.4.10 The system shall edit to prevent
duplicate billing of Durable Equipment (DE) and Durable Medical
Equipment (DME). Consequently, the system shall edit
to ensure that all DME items billed by HHAs have a line-item date
of service and Healthcare Common Procedure Coding System (HCPCS) coding,
though home health CB does not apply to DME by law.
3.5 Episode
/Period Data
Requirement
The contractor’s
authorization screen (part of its automated authorization file)
shall show whether or not the beneficiary is currently in a home
health episode/period of care (being
served by a primary HHA), along with the following information:
3.5.1 The beneficiary’s name and
sex.
3.5.2 Pertinent contractor and provider
number.
3.5.3 Episode/Period
Start and End Dates. The start date is received on a RAP or claim,
and the end date is initially calculated to be the 60th or
30th day after the start date, changed as necessary when
the claim for the episode/period is
finalized.
3.5.4 Date of Earliest Billing Action
(DOEBA) and DOLBA. Dates of earliest and latest billing activity.
3.5.5 Period Status Indicator. The
patient status code on HHA PPS claim, indicating the status of the
HH patient at the end of the period.
3.5.6 Transfer/Readmit Indicator.
Point of origin codes taken from the RAP or claim as an indicator
of the type of admission (transfer, readmission after discharge).
3.5.7 The Health Insurance PPS (HIPPS)
Code(s). Up to six for any episode/period,
representing the basis of payment for episodes/periods other
than those receiving a LUPA.
3.5.8 Principle Diagnosis Code and
First Other Diagnosis Code. From the RAP or overlaying claim.
3.5.9 A LUPA Indicator. Received
from the system indicating whether or not there was a LUPA episode/period;
and
3.5.10 At least six of the most recent
episodes/periods for any beneficiary.