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 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.
3.1.4 The contractor 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 shall coordinate
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.
3.2.1.1.1 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.
3.2.1.1.2 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 calendar days or 30 calendar
days of previous discharge).
3.2.1.3 The contractor shall maintain
responsibility for designating primary provider status under the
HHA PPS in each case.
3.2.2 Data
Requirement/Maintenance
The Tax
Identification Number (TIN) (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/Period
While
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.
3.3.3.1 The contractor 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.
3.3.3.1.1 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.
3.3.3.1.2 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 calendar 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 The contractor
shall return system-rejected claims to the HHA for correction. 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. 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 The contractor shall return
the claims rejected by the system to providers, 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).
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/Periods
3.4.1 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 an 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 must 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 Dates of Latest Billing Action
(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.