Module 1, Topic 1
In Progress

Day 1: Request for Anticipated Payment (RAP)

Petria September 3, 2020

Request for Anticipated Payment RAP

TYPE OF BILL 322

Medicare Claims Processing Manual Chapter 10 – Home Health Agency Billing

10.1.12 – Request for Anticipated Payment (RAP) (Rev. 4489, Issued: 01-09-20, Effective: 01-01-20, Implementation: 07-01-19) The HHA submits a RAP to their A/B MAC (HHH) to request the initial split percentage payment for an HH PPS episode/period. The RAP may be submitted after receiving verbal orders and delivering at least one service to the beneficiary. Though they are submitted on standard institutional claim formats, the RAP is not considered a Medicare home health claim and is not subject to many of the stipulations applied to claims in regulations. (NOTE: RAPs may be considered claims for purposes of other Federal laws and regulations.) In particular, RAPs are not subject to the payment floor, are not subject to interest payment if delayed in processing, and do not have appeal rights. Appeal rights for the episode are attached to claims submitted at the end of the episode. In addition to a split percentage payment (see §10.1.6), RAPs may be paid zero percent if:

  • Medicare is the secondary payer (see §30.10), or
  • a provider has lost the privilege of receiving RAP payment,
  • the beneficiary is enrolled in a Medicare Advantage plan, or
  • for periods of care beginning on January 1, 2020, is a new provider with a participation date on or after January 1, 2019.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf

Split-Percentage Payments

Beginning in CY 2020, HHAs that are certified for participation in Medicare on or after January 1, 2019, will no longer receive split-percentage payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, would still be required to submit a “no pay” Request for Anticipated Payment (RAP) at the beginning of care to establish the HH period of care, as well as, every 30 days thereafter upon implementation of the PDGM in CY 2020.

Existing HHAs, meaning those HHAs certified for participation in Medicare prior to January 1, 2019, will continue to receive RAP payments upon implementation of the PDGM in CY 2020. For split percentage payments to be made, existing HHAs would have to submit a RAP at the beginning of each 30-day period of care. For all 30-day periods of care, the split percentage payment will be 20/80.

 

Purpose of the RAP

  • Notifies Medicare of the primary home health agency for each episode
  • Begins each 60 day episode; 30 day period under PDGM
  • Posts the episode to Common Working File or HETS
  • Alerts the payment system of the HIPPS code that will be used to calculate the payment
  • Allows the agency to receive the initial payment 20% under PDGM
  • Alerts other home health agencies that the patient is already on service

 

Request for Anticipated Payment (RAP)

RAP general information:

  • RAP may be submitted based on a verbal order
  • RAP may NOT be submitted until the agency has completed the first billable visit within each episode/period; exception
  • Rap not subject to payment floor
  • RAP subject to MSP – takes longer to process Z=$0
  • RAP can auto cancel:
    If the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date ofthe RAP, the RAP payment will be canceled automatically by Medicare claimsprocessingsystems

 

Request for Anticipated Payment (RAP)

Though RAPs are submitted on standard institutional claim formats, the RAP is not considered a Medicare home health claim and is not subject to many of the stipulations applied to claims in regulations. (NOTE: RAPs may be considered claims for purposes of other Federal laws and regulations.)

In particular, RAPs are not subject to the payment floor, are not subject to interest payment if delayed in processing, and do not have appeal rights.
In addition to a split percentage payment, RAPs may be paid zero percent if:

  • Medicare is the secondary payer, or
  • a provider has lost the privilege of receiving RAP payment,
  • the beneficiary is enrolled in a Medicare Advantage plan, or
  • for periods of care beginning on January 1, 2020, is a new provider with a participation date on or after January 1, 2019.

 

RAP Split Percentage Payment – 20%

Medicare makes a split percentage payment for most HH PPS episodes/periods. The first payment is in response to a RAP, and the last in response to a final claim. Added together, the first and last payment equal 100 percent of the permissible payment for the episode.

In the final rule, CMS stated they “believed that the split percentage approach to payment may no longer be needed for HHAs to maintain adequate cash flow” in PDGM.

For periods of care beginning on or after January 1, 2020, the Grouper software is incorporated in Medicare claims processing systems. The Grouper will use claims data and OASIS data from the CMS quality data repository to assign the HIPPS code used for payment on the claim.

Note: There is no need for the TAC anymore.

 

Grouper Software

Once the OASIS has gone through the Grouper Software it will create a HIPPS code.

HIPPS (Health Insurance Perspective Payment System) codes are equivalent to a specific dollar amount for reimbursement.

 

Recoding Based on OASIS-calculated HIPPS Codes

The HIPPS code calculated based on the OASIS assessment for an episode is reported on the HH RAP and claim. HHAs may calculate the HIPPS code using CMS-provided Grouper software or with their own software that recreates CMS grouping logic. When the OASIS assessment is submitted to the Medicare quality system, the HIPPS code is independently calculated using the CMS-provided Grouper program. When processing the claim for an episode, Medicare systems compare the provider-submitted HIPPS code with the HIPPS code calculated based on the assessment information in the quality system. If the codes do not match, the OASIS-calculated HIPPS code is used for payment.