Program_Memos / 2000 / AB-00-65

Why This Topic Matters

It documents the Medicare home health payment transition and the related claims-processing, system, and administrative changes that affected providers, intermediaries, and software systems at implementation.

Article Sections

1. Background Information

   Provides statutory, regulatory, and administrative context for the home health payment transition. Summarizes the broad system changes and implementation framework described in the memorandum.

2. Specific Business and Systems Requirements

   Outlines the operational requirements organized by topic area. Covers provider, claims, system, notice, review, pricing, and transition-related subjects across the HH PPS implementation.

3. Implementing the A-B shift under HH PPS

   Describes system handling for the Medicare Part A and Part B payment split under the new home health payment environment. Focuses on claims processing and internal file updates.

4. Provider Change of Ownership (CHOW)

   Addresses provider ownership changes and their effect on home health payment processing. Discusses how claims and episode records are handled when provider identifiers change.

5. General Claim Requirements

   Summarizes general claim-format and submission requirements for home health episodes. Includes payment representation, billing limitations, and related processing topics.

6. Coordination of Benefits (COB)

   Covers coordination of benefits processing in the home health claims environment. Describes how claims are transmitted for coordination purposes.

7. Enforcement of Consolidated Billing

   Describes consolidated billing-related edits and billing controls for home health services. Includes discussion of interactions with other provider types and claim types.

8. Audit and Reimbursement/PS&R Requirements

   Addresses provider statistics, reimbursement tracking, cost reporting, and related audit functions. Summarizes reporting and settlement considerations during the transition period.

9. Common Working File (CWF) Requirements

   Explains episode file maintenance, claim-to-episode edits, and inquiry functions in the Medicare claims environment. Covers beneficiary episode tracking and related response handling.

10. Demand Billing and Appeals

    Discusses appeals and demand billing concepts in the home health prospective payment setting. Notes how existing processes are adapted for the new system.

11. Education issues for providers

    Outlines provider education and outreach activities related to the new home health payment system. Includes coordination for multiple provider and stakeholder groups.

12. The HH PPS Episode

    Defines the episode concept used in home health prospective payment. Addresses how episodes are understood and managed across overlapping or related care periods.

13. Claim Requirements

    Covers claim submission, processing, timing, and episode finalization requirements. Includes treatment of partial episodes, no-rap situations, and claim adjustments.

14. Medical Review Requirements

    Describes medical review considerations tied to home health claims and episode records. Includes reviewer access, messaging, and review-related processing.

15. Beneficiary Notices

    Summarizes notice and remittance-related communications that beneficiaries may receive. Addresses message updates and document modifications for the new payment system.

16. Medicare Secondary Payer (MSP)

    Explains how secondary payer processing fits into the home health prospective payment environment. Covers claims handling and related system coordination.

17. National Claims History (NCH) Requirements

    Describes how home health transaction data is stored and processed in national claims history files. Notes how reporting and analytical files are affected.

18. Outcomes and Assessment Information Set (OASIS) Related Requirements

    Addresses the relationship between OASIS data and payment processing. Covers assessment timing, matching keys, and system ties between clinical and billing data.

19. HH PPS Pricer Requirements

    Summarizes the pricing system requirements used for home health payment calculation. Covers inputs, outputs, annual updates, and claim-handling logic at a high level.

20. Remittance Advice Instructions

    Explains remittance reporting changes for home health payment processing. Includes line-level reporting, reversal handling, and payment presentation topics.

21. Request for Anticipated Payment (RAP) Requirements

    Describes the submission and processing framework for RAP transactions. Focuses on provider instructions, system handling, and related episode opening functions.

22. RHHI file maintenance

    Covers file setup and maintenance tasks for regional home health intermediaries. Addresses code file updates and provider-specific file attributes.

23. Standard System editing requirements

    Lists system edits and interface requirements for standard claims processing systems. Includes interactions with episode processing, payment systems, and related files.

24. Transition to HH PPS

    Describes the transition period between the prior home health payment methodology and HH PPS. Focuses on timing, overlap handling, and billing cutover issues.

25. Workload Reporting and Claims Timeliness

    Addresses workload reporting and timeliness considerations during implementation. Notes how RAPs and claims are tracked for operational reporting.

26. Enhancements to the HH PPS system

    Identifies later system enhancements planned after initial implementation. Covers follow-on improvements to processing, inquiry, and pricing support.