Configuration of the HH PPS Environment

10.1.3 - Configuration of the HH PPS Environment (Rev. 2230, Issued: 05-27-11, Effective: 08-28-11, Implementation: 08-28-11) The configuration of Medicare home health claim processing is similar to previous Medicare claims processing systems. The flow from the HHA at the start of billing, to the receipt or remittances and electronic funds transfer (EFT) by the agency, to the recording of payment in either billing or accounting systems (bill/acct software) can be envisioned as follows: CWF SS/Contractor Front End SS/Contractor Back End PRICER PS&R Grouper Billing Software Bank Bill./ Acct. Software At HHA At HHA At Contractor At CWF Host Inquiries RAP/Claim Batches Inquiries Claims EFT Payment Remittances Checks RAPs Subsystems, also known as drivers or software applications or modules, have been created for HH PPS for Medicare home health claims processing. • Grouper determines HHRGs for claims at HHAs by inputting OASIS data. (OASIS is the clinical data set that currently must be completed by HHAs for patient assessment.) OASIS software was updated to integrate the Grouper from the advent of HH PPS, and CMS has made Grouper specifications available on its Web site for those designing their own software. • ELGH is an inquiry system in CWF available via A/B MAC (HHH) remote access, through which HHAs and other providers can ascertain if a home health episode has already been opened for a given beneficiary by another HHA, and track episodes of beneficiaries for whom they are the primary HHA. HHAs may also access this information via the HIPAA Eligibility Transaction System or HETS. Refer to §§30.1 and 30.2 for a detailed description. Pricer software is used to process all HH PPS claims and is integrated into the Medicare claims processing systems. In addition to pricing HIPPS codes for HHRGs, this software maintains national standard visit rate tables to be used in outlier and LUPA determinations. Refer to §70 for a detailed description of the Pricer software.