General Guidelines for Processing Home Health Agency (HHA)

10 - General Guidelines for Processing Home Health Agency (HHA) Claims (Rev. 2977, Issued; 06-20-14, Effective: 09-23-14; ICD-10: Upon Implementation of ICD-10, Implementation: 09-23-14; ICD-10: Upon Implementation of ICD-10) This chapter, in general, describes billing and claims processing requirements that are applicable only to home health agencies. For general bill processing requirements refer to the appropriate other chapters in the Medicare Claims Processing Manual. For a description of home health coverage policies see Pub. 100-02, Medicare Benefit Policy Manual, chapter 7. A. Where and How to Bill Institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837 institutional claim. The minority of providers that are eligible for an exception to electronic claim submission use the paper Form CMS-1450, also known as the UB-04. Such claim forms are submitted to certain Medicare Administrative Contractors (A/B MACs (HHH)) with jurisdiction over home health and hospice claims. Some home health agencies may also become approved as Durable Medical Equipment (DME) suppliers, in which case they would submit bills for DMEPOS services to the DME MACs on a professional claim format (the 837professional or paper Form CMS-1500). References to the claim form in this chapter refer to the paper Form CMS-1450 unless otherwise noted. However, the instructions regarding specific data requirements apply also to the electronic 837 institutional claim. B. Services to Include on the Claim for Home Health Benefits Effective for all services provided on or after October 1, 2000, all services under the home health plan of care, except the following, are included in the home health PPS payment amount. Services that may be included in the plan of care but excluded from the HH prospective payment system (HH PPS) are: • Osteoporosis drugs (although the cost of administration is within the PPS rate); and • Durable medical equipment, including prosthetics, orthotics, and oxygen The DMEPOS services may be included on type of bill (TOB) 032x for the home health benefits, and are paid in addition to the PPS payment. See §20 for additional instructions regarding competitively bid DME. Osteoporosis drugs must be billed on type of bill 034x. Other services not under an HH plan of care provided by an HHA are billed using type of bill 034x. See §90 for guidance as to the payment methodologies used by Medicare to reimburse these services, and see §40.4 in this chapter for information on deductible and coinsurance.