Module 1, Topic 1
In Progress

Day 2: Submission of Request for Anticipated Payment (RAP)

Petria September 3, 2020

Submission of Request for Anticipated Payment (RAP)

The HHA can submit a Request for Anticipated Payment, or RAP, to Medicare when all of the four following conditions are met.

  • After the OASIS assessment is complete, locked or export ready, or there is an agency-wide internal policy establishing the OASIS data is finalized for transmission to the national assessment system;
  • Once a physician’s verbal orders for home care have been received and documented;
  • A plan of care has been established and sent to the physician; and
  • The first service visit under that plan has been delivered.

An episode/period will be opened on CWF with the receipt and processing of the RAP. HHAs should submit the RAP as soon as possible after care begins in order to assure being established as the primary HHA for the beneficiary. RAPs are submitted using TOB 0322. The HH Pricer software will determine the first of the two split percentage payments, which is made in response to the RAP, which is 20% of the total reimbursement for that 30 day period.

Each RAP must be based on a current OASIS based payment group represented by a HIPPS code. In general, a RAP and a claim will be submitted for each episode period.

Each claim, usually following a RAP and at the end of period, must represent the actual utilization over the entire period.

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 of the RAP, the RAP payment will be canceled automatically by Medicare claims processing systems.

 

 

RAP Reminders

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 of the RAP, the RAP payment will be canceled automatically by Medicare claims processing systems, however:

  • If a RAP is canceled you may re-bill the RAP
  • The re-billed RAP must match the canceled RAP exactly
  • Not sequential billing
  • RAPs can get tricky. Failure to establish proper billing protocol, smart work flows and procedures around RAPs can create crippling cash flow issues
  • If there is a Medicare Secondary Payer or the patient is enrolled in a Medicare Advantage Plan, it will result in a zero payment, or “Z-RAP”.
  • Also, if your agency has what Medicare deems are too many takebacks, all RAPs will be set to pay at zero percent instead of 20. This is called RAP Suppression

 

 

Payment, Claim Adjustments and Cancellations for RAPs

A number of conditions can cause the episode/period payment or the RAP to be adjusted or cancelled.

The HHA must cancel a RAP sent in error.
RAPs cannot be adjusted.
They may be rebilled with appropriate information after cancellation. Type of bill 0328 is used for a cancel transaction, for both claims and RAPs.

 

 

Future Proposal New RAP Rules for 2021

  • Split percentage payments will be zero for all HHAs and for all 30 day periods, on or after January 1, 2021
  • HHAs will submit a “no-pay” RAP at the beginning of each 30 day period
  • The “no-pay” RAP for all HHAs in CY 2021 will require less information. They can be made when the following criteria have been met:
  • The doctor’s written or verbal order has been received
  • The initial visit within the 60 day certification period has been made and the individual admitted to home health care
  • CMS will allow the advance submission of certain RAPs in CY 2021 where the POC dictates that multiple 30 day periods will be required to effectively treat the patient. HHA will submit both 30 day period RAPs at the same time to help reduce provider administrative burden
  • A non timely submission reduction in payment for late submission of any “no pay” RAPs when the HHA does not submit the RAP within 5 calendar days from the SOC date for the 1st 30 day period in a 60 day certification period and within 5 calendar days of day 31 for the 2nd 30 day period of care in the 60 day certification period.
  • The reduction in payment would be equal to a 1/30th reduction to the wage adjusted 30 day period payment amount for each day from the SOC date until the date the HHA submits the “no pay” RAP

The information needed to submit a “no-pay” RAP will mirror the NOA policy

 

 

Future Proposal for New RAP Rules for 2022

  • RAPs submission will be eliminated
  • A one time NOA (Notice of Admission) will be submitted within 5 calendar days from the SOC date
  • The NOA submission criteria has to be met:
    • The doctor’s written or verbal order has been received
    • The HHA has conducted an initial visit at the SOC
    • There will be a non timely submission reduction in payment for late submission of NOAs when the HHA does not submit the NOA within 5 calendar days from the SOC date.
    • The reduction in payment would be equal to a 1/30th reduction to the wage adjusted 30 day period payment amount for each day from the SOC date until the date the HHA submits the NOA

The information needed to submit a “no-pay” RAP will mirror the NOA policy

 

 

RAP Home Health Billing Instructions for Overlap Services

When the National Uniform Billing Committee (NUBC) replaced the UB-92 institutional claim form with the UB-04, it made several changes to the names and definitions of claim fields. One of these changes was to redefine the “Source of Admission” field as “Point of Origin for Admission or Visit” and to specify that codes in this field must represent a place, rather than a referral source. NUBC was then called upon to revise point of origin codes for UB-04 billing to accommodate data reporting required for quality measures that are used to determine annual Medicare payment updates for hospitals.

NUBC has determined that the new point of origin codes, including the retirement of codes B and C, will be effective for dates of service on or after July 1, 2010. In order to accommodate PEP indicators for transfer from another home health agency, NUBC has created a new condition code, code 47, to replace the point of origin code B. The title of this new code 47 is “Transfer from Another Home Health Agency.” The code is defined: “The patient was admitted to this home health agency as a transfer from another home health agency.” It was determined that it was not necessary for NUBC to replace point of origin code C for readmission to the same agency.

 

 

Institutional vs. Community

  • Only the 1st 30-day period will be considered “Institutional”
  • All subsequent periods to be considered “Community”

PDGM rule has changed will affect the overall strategy & practices of how HH providers approach referrals & what defines a desirable referral source

Determination made by looking back at 14 days prior to admission to look for institutional stay

 

 

Early vs. Late Determination

In PDGM, 30 day billing periods

  • Only the first claim is early, not the first two episodes
  • 34% average reduction in reimbursement for early / late change

Must be more than 60 days between end of one period & start of another period to be early again

 

 

Final Billing Methodology

For billing purposes, PDGM will keep the RAP/Final billing methodology

PDGM RAP 2 in most cases will use the same OASIS as PDGM RAP 1 leading to quicker billing timeline

 

Exception

The one exception to reporting a visit date on the 0023 revenue code of the RAP is when no visits are expected during a 30-day period of care. For instance, if the beneficiary’s plan of care requires that the beneficiary is seen every 6 weeks and there is a recertification, the beneficiary might receive no visits in the first 30-day period following the recertification. In this case, the HHA should submit a RAP for all 30-day periods, but only submit claims for 30-day periods in which visits were delivered.

If no visits are expected during an upcoming 30-day period, the HHA should submit the RAP with the first day of the period of care as the service date on the 0023 line. The RAP for a period with no visit will ensure the HHA remains recorded on Medicare’s Common Working File (CWF) system as the primary HHA for the beneficiary and will ensure that HH consolidated billing is enforced. If no visits are provided, the RAP will later be autocancelled to recover the payment.