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Home Health Claims Filing

The Fiscal Intermediary Standard System (FISS) Claims/Attachments option 26 (accessible from FISS Main Menu Option 02) allows you to enter home health Requests for Anticipated Payments (RAPs) and final claims. The following provides screen prints and field descriptions for each FISS claim page and identifies which fields are required for RAPs, final claims, and home health outpatient claims, and the data required in those fields. Information is also provided about special claims filing situations.

For more information about the Home Health Prospective Payment System (HH PPS), go to the Home Health Prospective Payment SystemExternal Website booklet, which is available on the Centers for Medicare & Medicaid Services (CMS) website, and the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 10)External PDF. In addition, please see the references on the CMS Home Health Agency (HHA) CenterExternal Websiteweb page, as well as the resources listed on the CGS Educational Materials & Resources web page.

Split Percentage Payment
Medicare makes a split percentage payment for most HH PPS episode periods. The first payment is in response to a processed RAP, and the last in response to a processed claim.  If the claim is not received 120 days after the start date of the episode or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by FISS and will be recouped.  In order to receive payment, the RAP must be resubmitted and a final claim billed timely.  For additional information, refer to section 40.1 of the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 10)External PDF, or the Top Claim Submission Errors for Home Health Providers: Error 38107 web page. Starting in calendar year 2021, the split percentage payment will be lowered to 0 percent; however, home health agencies would still be required to submit a RAP at the beginning of each 3-day period of care under the home health Patient Driven Groupings Model (PDGM).  Refer to MM11855External PDF for additional information.

HH PPS

There are six claim pages within FISS (for claims with the “From” date prior to January 1, 2020):

Home Health Patient Driven Groupings Model (PDGM)

Effective with claim “From” dates on or after January 1, 2020, home health claims are submitted under the PDGM.  Refer to the Home Health Patient-Driven Groupings Model (PDGM) web page for additional information, and to the following for billing instructions.

Special Claims Filing Situations

Additional Resources

Medicare Billing: Form CMS-1450 and the 837 InstitutionalExternal Website

This CMS booklet offers an overview of the 837I and CMS-1450 (UB-04), which is used by institutional providers to submit claims electronically or when a paper claim is allowed, and may be suitable for billing various government and some private insurers.

Consolidated Billing Master Supply ListZip File

This list is maintained and updated annually by CMS and contains the nonroutine supplies that are included in consolidated billing under the HH PPS.

Timely Filing Requirements

Section 6404 of the Patient Protection and Affordable Care Act (PPACA) amended the timely filing requirements to reduce the maximum time period for submission of all Medicare claims, including adjustments and cancels, to one calendar year after the date of service.

Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 10)External PDF

Chapter 10 of the Medicare Claims Processing Manual describes bill processing requirements that are applicable only to home health agencies.

National Uniform Billing Committee (NUBC)External Website

Refer to the NUBC website for a complete description of all the items included on the CMS-1450 (UB-04) claim form.

Home Health Quick Resource Tools

A variety of tools developed by the CGS Provider Outreach and Education staff are available to assist in the successful processing of your claims.

Updated: 09.15.20

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