Posted December 18, 2019 via
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).
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 patients 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 OptionExtended Home Health Care (ECHO-EHHC) benefit. Reimbursement for services covered under ECHO-EHHC is based on the CMAC.
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 184.108.40.206.2).
Providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim.
Tips for filing a RAP*:
Pos 12: Start-of-care date two-digit year (for example, 18 for 2018)
Pos 34: Start-of-care date alpha code for Julian date (for example, 245 = JK)
Pos 56: Date assessment completed two-digit year (for example, 18 for 2018)
Pos 78: 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:
*Billing tips are based on current Centers for Medicare & Medicaid Services (CMS) guidelines. Please refer to www.cms.gov as requirements may change.
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December 13, 2019 via go.myhomecarebiz.com
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