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Home Health Billing

Home Health Billing

Under TRICARE, home health agency providers must follow Medicare guidelines and the TRICARE Reimbursement Manual, Chapter 12 when submitting claims for home health care to Health Net Federal Services, LLC (HNFS). ##Prospective Payment System The TRICARE benefit for home health care services closely follows Medicare’s Home Health Agency Prospective Payment System (HHA-PPS). Medicare-certified billing is handled in 60-day-care episodes, allowing home health agencies to receive two payments of 60 percent and 40 percent, respectively, per 60-day cycle. This two-part payment process is repeated with every new cycle, following the patient’s initial 60 days of home health care. Medicare updates HHA-PPS rates annually on a calendar year basis. 

  • For non-pregnant adults (18 years of age or greater) who are receiving services from Medicare-certified home health agencies, TRICARE only allows for HHA-PPS reimbursement. The CHAMPUS maximum allowable charge (CMAC) does not apply. 
  • For pediatric or pregnant beneficiaries who are receiving services from Medicare-certified home health agencies, HHA-PPS reimbursement applies. If there is not a Medicare-certified home health agency available, HNFS may authorize skilled therapy, social work or skilled nursing home health services to a non-Medicare certified, but state-licensed agency that is under a Corporate Services Provider participation agreement. In this instance, CMAC reimbursement would be allowed.

Note: This guidance does not apply to home health services provided to active duty family members under the Extended Care Health Option–Extended Home Health Care (ECHO-EHHC) benefit. Reimbursement for services covered under ECHO-EHHC is based on the CMAC. ##Outcome and Information Assessment Set (OASIS) Medicare-certified home health agencies are required to conduct abbreviated OASIS assessments for beneficiaries who are under the age of 18 or receiving maternity care for payment under the HHA-PPS. This requires the manual completion and scoring of a Home Health Resource Group (HHRG) worksheet in order to generate a Health Insurance Prospective Payment System (HIPPS) code. The abbreviated 23-item assessment (as opposed to the full 79-item comprehensive assessment) provides the minimal amount of data required to generate the HIPPS code, a required element on home health claims (see below).  ** Note: ** OASIS assessments are not required for authorized care in non-Medicare certified HHAs that qualify for Corporate Services Provider status under TRICARE (TRICARE Reimbursement Manual, Chapter 12, Section 1, paragraph  ##Claim Requirements Providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim. Tips for filing a RAP*:

  • The bill type in Form Locator (FL) 4 of the UB-04 is always 322.
  • The “To” date and the “From” date in FL 6 must be the same and must match the date in FL 45.
  • FL 39 must contain value code 61 and the Core-Based Statistical Area code of the beneficiary’s residential address.
  • As of Jan. 1, 2019, home health agencies in rural areas must also include value code 85 and the associated Federal Information Processing Standards (FIPS) state and county code where the beneficiary resides. 
  • There must be only one line on the RAP, and it must contain revenue code 023 and 0 dollars. On this line, FL 44 must contain the HIPPS code.
  • The quantity in FL 46 must be 0 or 1.
  • FL 63 must contain the authorization code assigned by the OASIS. ** Note: ** This is not an HNFS/TRICARE authorization number. The 18-digit OASIS authorization code contains (example 18JK18AA41GBMDCDLG):

Pos 1–2: Start-of-care date – two-digit year (for example, 18 for 2018) Pos 3–4: Start-of-care date – alpha code for Julian date (for example, 245 = JK) Pos 5–6: Date assessment completed – two-digit year (for example, 18 for 2018) Pos 7–8: Date assessment completed – alpha code for Julian date (for example 001 = AA) Pos 9: Reason for assessment 04 = 4 Pos 10: Episode Timing – Early = 1, Late = 2; 01 = 1 Pos 11: Clinical severity points – under Equation 1; 7 = G Pos 12: Functional severity points – under Equation 1; 2 = B Pos 13: Clinical severity points – under Equation 2; 13 = M Pos 14: Functional severity points – under Equation 2; 4 = D Pos 15: Clinical severity points – under Equation 3; 3 = C Pos 16: Functional severity points – under Equation 3; 4 = D Pos 17: Clinical severity points – under Equation 4; 12 = L Pos 18: Functional severity points – under Equation 4; 7 = G Tips for filing a final claim:


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