March 9, 2021
RAPs and LUPAs: What You Need to Know
The Home Health & Hospice Provider Contact Center (PCC) have experienced an increase in calls from providers about untimely RAPs for Low Utilization Payment Adjustment (LUPA) claims. The implementation of the Patient-Driven Groupings Model (PDGM) changed LUPA thresholds from the four or fewer visits to a threshold range between 2 and 6 visits. Therefore, for home health periods of care beginning on or after January 1, 2020, it was more challenging to predict when a period of care will result in a LUPA.
With the implementation of Change Request 11855 (MM11855) a home health agency could decide not to submit a Request for Anticipated Payment (RAP) if they knew in advance that the period of care resulted in a no-RAP LUPA. However, as a reminder, effective January 1, 2021, if a RAP is filed for a LUPA, the RAP must be filed timely. If a RAP is filed for a LUPA, and is not submitted timely, the non-timely submission payment reduction will be applied.
There are four circumstances that may qualify for an exception of filing a RAP more than 5 calendar days after the period of care From data (see MM11855). To request an exception, add modifier KX to the HIPPS Code reported on the revenue code 0023 line on the claim. In addition, enter information supporting the circumstance that applies to the RAP in the REMARKS field on the Claim (FISS Claim page 04).
To determine the LUPA threshold for each of the 432 case-mix groups, refer to the Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator. Please share this with your appropriate staff.