April 7, 2021
What You Need to Know About the Home Health RAP Penalty
As of January 2021, a payment reduction applies on home health claims when the request for anticipated payment (RAP) is not submitted timely. The payment reduction will equal 1/30th of the 30-day period payment amount for each day from the start of care date/admission date, or “from date” for subsequent 30-day periods, until the date the RAP is submitted.
Home Health Agencies (HHAs) can review the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) and their Remittance Advice to identify when a RAP penalty is applied.
- Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE)
The RAP penalty displays on FISS DDE Claim Page 01 with the value code QF and the amount of the payment reduction. It also displays the Claim Adjustment Group Code CO (contractual obligation), and Claim Adjustment Reason Code (CARC) 95.
FISS DDE Example– Page 01
- Medicare Standard Paper Remittance (SPR) Advice
The Medicare Standard Paper Remittance (SPR) Advice will display CARC code 95 under the RC field and the remark code MA01 in the REM field. The remark code MA01 indicates that if you disagree with what was approved for these services, you may appeal the decision by submitting a Redetermination (first level of appeal).
SPR Advice Example
The total payment reduction amount for all claims that appear on the SPR with the RAP penalty will display in the Adjustment to Balance field.
Requesting an Exception
HHAs may request an exception if the RAP is filed untimely, more than 5 calendar days after the period of care, by adding the KX modifier to the final claim. Refer to the Submitting a Final Claim under the Home Health Patient-Driven Groupings Model for additional information.
When CGS reviews the supporting information provided in the REMARKS field, or submitted documentation and determines that the information does not support the exception request, the penalty will still apply. HHAs 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.
Note: Do not submit an adjustment to request a second request for an exception.
Resources:
- MM11855
, Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation. - Submitting a Final Claim under the Home Health Patient-Driven Groupings Model CGS web page
- 1st Level of Appeal – Redetermination CGS web page
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