Submitting a Final Claim under the Home Health Patient-Driven Groupings Model
Effective for home health periods of care beginning January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient-Driven Groupings Model (PDGM) as described in the Calendar Year (CY) 2019 home health (HH) final rule (CMS-1689-FC
). The PDGM changes the unit of payment from 60-day episodes of care to 30-day periods of care and eliminates the therapy thresholds used in determining home health payment.
The following information provides details about submitting a final claim, including data elements needed when entering a final claim using the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). The corresponding UB-04 Form Locator (FL) is also identified. Select the topic below to access.
- When to Submit a Final Claim (With FROM dates on or after January 1, 2020) Links all these bullet points to the corresponding headings below.
- RAP Payment Recouped (prior to January 1, 2021)
- Requesting an Exception for an Untimely RAP Submission (Effective January 1, 2021)
- Low Utilization Payment Adjustments (LUPA)
- Timely Filing of Final Claim (prior to January 1, 2021)
- Periods of Care with No Visits Expected
- Inpatient Stays Spanning the End of a 30-day Period
- Claim Submission Data Elements
When to Submit a Final Claim (With FROM dates on or after January 1, 2020)
A home health final claim is submitted after the Request for Anticipated Payment (RAP) has been processed, after the 30-day period has ended, or if the patient has been transferred or discharged. In addition, prior to submitting the final claim, ensure that:
- All services have been provided for the period and the physician has signed the plan of care and all verbal orders.
- Face-to-face encounter has been completed.
- The Outcome and Assessment Information Set (OASIS) is submitted and accepted in the state repository
RAP Payment Recouped (prior to January 1, 2021)
When the RAP is processed, a split percentage payment of 20 percent is made for initial and subsequent periods of care. When the final claim is submitted timely and processes, the RAP payment will be recouped and the final claim will receive the full PDGM payment.
The RAP payment will be recouped, if the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP.
Requesting an Exception for an Untimely RAP Submission (Effective January 1, 2021)
Starting in CY 2021, a payment reduction will apply when the HHA does not submit the RAP within 5 calendar days from the start of care date ("admission date" and "from date" on the claim will match the start of care date) for the first 30-day period of care in a 60-day certification period, and within 5 calendar days of the "from date" for the second 30-day period of care in the 60-day certification period. The payment reduction will be equal to a 1/30th reduction to the 30-day period payment amount for each day from the home health start of care date/admission date, or "from date" for subsequent 30-day periods, until the date the HHA submits the RAP.
When the final claim is processed with the payment reduction applied, the value code QF will display the penalty amount.
An HHA may request an exception if the RAP is filed more than 5 calendar days after the period of care. The four circumstances that may qualify for an exception are:
- Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA's ability to operate
- An event that produces a data filing problem due to a CMS or CGS system issue that is beyond the control of the HHA
- A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from CGS.
- Other circumstances determined by CMS or CGS to be beyond the control of the HHA.
To request an exception, enter information supporting the circumstance (listed above) that applies to the RAP in the REMARKS field on the Claim (FISS Claim page 04). For example, if the RAP to a claim was originally received timely but the RAP was canceled and resubmitted to correct an error, enter in the REMARKS field "Timely RAP, cancel and rebill". Add modifier KX to the HIPPS Code reported on the revenue code 0023 line. HHAs should resubmit corrected RAPs promptly (generally within 2 business days of canceling the original RAP). Refer to Examples of Denied/Granted RAP Exception Requests for assistance.
If the information provided in the REMARKS field is not clear, CGS will request documentation by generating a non-medical review additional development request (non-MR ADR). HHAs will need to submit documentation supporting the exception request. When a non-MR ADR is generated, the claim will be moved to status/location S B6001. To learn more about how to check for non-MR ADRs, refer to the "Accessing Additional Development Request (ADR) Information" section in the FISS Guide Chapter 3: Inquiry Menu
.
Rights for Unfavorable Exception Requests
If the review of the information provided in the REMARKS field, or the submitted documentation does not support the exception request, the penalty will still apply. At that point, the home health agency may appeal the penalty amount applied to the final claim. Do not submit an appeal request for the RAP. Refer to the 1st Level of Appeal – Redetermination web page for additional information.
Refer to MM11855 – Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation for more information.
Low Utilization Payment Adjustments (LUPA)
Under PDGM, LUPA thresholds range between 2 and 6 visits; therefore, it is more challenging to predict when a period of care results in a LUPA. Effective January 1, 2021, if a RAP is submitted and is untimely, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. However, if a RAP is not submitted, and your claim is processed as a no-RAP LUPA claim, no penalty will apply. The payment reduction cannot exceed the total payment of the claim.
Refer to Home Health LUPA Threshold: Bill Correctly for more information.
Timely Filing of Final Claim (prior to January 1, 2021)
If the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by FISS and will be recouped. If the RAP payment is canceled, the RAP will need to be resubmitted. In addition, in cases when no visits are made during a 30-day period of care, the RAP will be auto-canceled to recover the payment. See MM1152
for additional information.
Periods of Care with No Visits Expected
In cases when a beneficiary's plan of care requires that the beneficiary is seen every 6 weeks and there is a recertification, there may not be any visits in the first 30-day period of care. In this case, only submit a final claim for 30-day periods in which visits were delivered. A RAP should still be submitted. The RAP for a period with no visit will ensure the home health agency (HHA) remains recorded on Medicare's Common Working File (CWF).
Inpatient Stays Spanning the End of a 30-day Period
Discharging the beneficiary is not required if they had an inpatient stay that spans the end of the first 30-day period of care in a certification period. Submit the RAP and claim for the period following the inpatient discharge as if the 30-day periods were contiguous – submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge.
Claim Submission Data Elements
Centers for Medicare & Medicaid Services (CMS), Pub. 100-04, Ch. 10, section 40.2
The following provides the data elements required on a home health final claim. The following table provides the required fields when submitting the claim via Direct Data Entry (DDE).
| Claim Submission Data Elements DDE FISS Claim Page 01 (Map 1711) |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
||||||||||||||||||||||||||||||||||
MID |
FL 60 |
Medicare ID – Enter the Medicare Beneficiary Identifier (MBI) number as it appears on the beneficiary's eligibility file. Refer to the Checking Beneficiary Eligibility Web page for details about the applications available to check eligibility. |
||||||||||||||||||||||||||||||||||
TOB |
FL 4 |
Type of Bill – Enter the final claim TOB 329. FISS Page 01 defaults to the home health claim TOB 322. Additional valid values are: 320 – Nonpayment claim |
||||||||||||||||||||||||||||||||||
NPI |
FL 56 |
National Provider Identifier – Enter your home health agency's NPI number. |
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STMT DATES FROM and TO |
FL 6 |
Statement Covers Period "From and Through" – Enter the beginning and ending dates for this billing period.
Note: When billing continuous care periods, there should not be a break in dates of service between the FROM date of the prior final claim and the FROM and TO dates of the subsequent RAP. In situations where there is an inpatient stay that spans the end of the first 30-day period, submit the RAP and claim for the period following the inpatient discharge as if the 30-day periods were contiguous – submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge. |
||||||||||||||||||||||||||||||||||
LAST |
FL 8 |
Beneficiary's Last Name – Enter the beneficiary's last name exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
FIRST |
FL 8 |
Beneficiary's First Name – Enter the beneficiary's first name exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
DOB |
FL 10 |
Date of Birth – Enter the beneficiary's date of birth (MMDDCCYY format) exactly as it appears on the beneficiary's eligibility file. |
||||||||||||||||||||||||||||||||||
ADDR 1-6 |
FL 9 |
Address – Enter the beneficiary's full mailing address, including street name, number, post office box number, city and state. |
||||||||||||||||||||||||||||||||||
ZIP |
FL 9 |
Zip Code – Enter the beneficiary's zip code of the city and state where they reside. |
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SEX |
FL 11 |
Sex – Enter the beneficiary's gender using the applicable alpha characters. M – Male; F – Female |
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ADMIT DATE |
FL 12 |
Admission Date – Enter the start of care date, which will be the same date of admission that was submitted on the RAP for the period. (MMDDYY format) |
||||||||||||||||||||||||||||||||||
SRC |
FL 15 |
Source of Admission – Now referred to as the point of origin. Valid values:
The above codes represent those most frequently submitted on home health RAPs/claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual |
||||||||||||||||||||||||||||||||||
STAT |
FL 17 |
Patient Discharge Status – Enter the appropriate patient status codes that reflects the patient status as of the "TO" date of the billing period. The following codes represent those most frequently submitted on home health RAPs/claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual
|
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COND CODES (conditionally required) |
FL 18-28 |
Condition Codes – Enter any NUBC
|
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OCC CDS/DATE |
FL 31-34 |
Occurrence Code and Date – Enter the occurrence code (OC) 50 and the OASIS assessment completion date. OC codes 61 and 62 are optional. 50 (required) – On all final claims, report OC 50 and the OASIS assessment completion date (OASIS item MO090) for the start of care, resumption of care, recertification or other follow-up OASIS that occurred most recently before the claim "From" date.
61 (optional) – Report OC 61 on admission claims and continuing claims, if applicable, to indicate the "Through" date of an acute care hospital discharge within 14 days prior to the "From" date of the HH claim. (See Note below.) Note: If OC 61 and 62 are not submitted, Medicare systems will use inpatient claim history to assign institutional payment groups based on the most current information. |
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FAC. ZIP |
FL 1 |
Facility Zip Code – Enter the 9-digit zip code of the provider or the subpart. |
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VALUE CODES |
FL 39-41 |
Value Codes and Amounts – Enter the following value codes/amounts. 61 – Enter 61 and the Core Based Statistical Area (CBSA) code that corresponds to the state and county code of the beneficiary’s place of residence at the end of the period of care. Access the Home Health Payment Rates Web page for these calendar year codes. Note: When entering a value code that represents a number rather than a monetary amount, enter the number followed by two zeros. For example, to indicate a CBSA code 99916, the number would be keyed as 9991600 or 99916.00. |
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Claim Submission Data Elements |
||
|---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
REV |
FL 42 |
Revenue Code – Enter the revenue code 0023 to report the HIPPS code. Only one 0023 revenue code line is entered. The HIPPS code must match the one submitted on the RAP for the period. Also report revenue codes for all services provided to the patient within the period. |
HCPC |
FL 44 |
Healthcare Common Procedure Coding – Enter the HIPPS code for the 0023 revenue code line (must match the same as RAP). For HCPCS codes as appropriate for all other reported revenue codes for the service provided. |
MODIFS |
FL 44 |
Modifier – Add modifier KX to the 0023 revenue code line to request an exception to a late RAP submission. |
TOT UNITS |
FL 46 |
Total Units – No units of service are required on the 0023 revenue code line. Units for service provided should reflect the number of 15-minute increments. For the Q code revenue code line, enter 1. |
TOT CHARGE |
FL 47 |
Total Charge – Enter the total charge for each revenue code line. The total charge for revenue code 0023 must be zero. For Q codes, enter a nominal charge (example – $0.01). |
NCOV CHARGE |
FL 48 |
Noncovered Charges – Enter any noncovered charges for each revenue code. Examples of noncovered charges on may include:
|
SERV DATE |
FL 45 |
Service Date – For the initial periods of care, enter the date of the first covered service provided on the 0023 revenue code line (same as RAP). For all other services provided, report the date (MMDDYY format) for each revenue code line. For Q codes, the service date entered must match the date of the first visit date in the episode. For subsequent periods of care, report the date of the first visit, regardless of whether it's a covered or noncovered visit. If the corresponding RAP for the subsequent period was submitted at the same time as the initial RAP was submitted (calendar year 2021 exception), report a service date on the 0023 revenue code line that matches the date submitted on the RAP. Reference: MM11855 |
Claim Submission Data Elements |
||
|---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
CD |
N/A |
Primary Payer Code – If Medicare is the primary payer, enter "Z" for Medicare. NOTE: If Medicare is the secondary payer and enter the appropriate MSP payer code. |
PAYER |
FL 50 |
Payer – When "Z" is entered in the CD field, FISS will automatically insert the payer name "Medicare" in this field. |
RI |
FL 52 |
Release of Information – Enter the appropriate valid value: Y – Provider has on file a signed statement permitting the provider to release data to other organizations |
DIAG CODES |
FL 67A – Q |
Diagnosis Codes – Enter the appropriate ICD code for the principal diagnosis code and any other diagnosis codes for conditions that coexisted when the plan of care was established. The diagnoses submitted on the claim and OASIS diagnoses are not expected to match in all cases. |
ATT PHYS |
FL 76 |
Attending Physician – Enter the NPI and name (last, first name required, middle initial optional) of the attending physician that established the plan of care with verbal orders. |
REF PHYS NPI, L, F, M |
FL 78 and 79 |
Referring Physician – Enter the NPI and name (last, first name required, middle initial optional) of the physician who certifies/recertifies the patient's eligibility for home health services. This is only required if the physician who certifies/recertifies is different than the physician who signs the plan of care. |
Claim Submission Data Elements |
||
|---|---|---|
DDE Field Name |
UB-04 Form Locator (FL) |
Description/Valid Values |
INSURED NAME |
FL 58 |
Insured Name – Enter the patient's name as shown on the Medicare card. |
CERT/SSN/MID |
FL 60 |
Medicare ID – Enter the Medicare Number as it appears on the Medicare card if it does not automatically populate. |
TREAT. AUTH. CODE |
FL 63 |
Treatment Authorization Code – Not required under PDGM. |
Updated: 05.10.2021
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