Requests for Anticipated Payment

Requests for anticipated payment are submitted at the beginning of every 60-day episode once the physician’s verbal orders have been obtained and the first Medicare billable service has been provided.

Table of Contents

• Payment
• Health Insurance Query for HHAs
• Conditions for Billing the RAP
• Four Types of RAP Submissions
• RAP Cancels
• Different RAP Cancels Cause Different Outcomes

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Payment

In order to ensure adequate cash flow to home health agencies, the home health PPS set forth a split percentage payment approach to the 60-day episode.

The split percentage occurs through the RAP at the start of the episode and the final claim at the end of the episode.

For initial episodes, there will be a 60/40 split percentage payment. An initial percentage payment of 60 percent of the episode will be paid at the beginning of the episode and a final percentage payment of 40 percent will be paid at the end of the episode, unless there is an applicable adjustment.

For all subsequent episodes for beneficiaries who receive continuous home health care, the episodes will be paid at a 50/50 percentage payment split.

RAPs are not subject to the payment floor or to interest because they are not considered Medicare claims as defined under the Social Security Act.

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Health Insurance Query for HHAs

An RAP must be submitted before the final claim of the episode. The RAP posts the episode to the CWF in the HIQH screen and populates the start and end dates.

If another RAP comes in within the same 60-day period of a previous episode and the previous episode does not have a final claim, the new RAP will automatically shorten the previous episode’s end date.

Note: Please see the Erroneous Episode Job Aid for instructions on how to resolve incorrect episodes.

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Conditions for Billing the RAP

The HHA can submit a RAP to Medicare when all of the four following conditions are met:

1. The OASIS assessment is complete, meaning it is locked or export ready, or there is an agency-wide internal policy establishing the OASIS data is finalized for transmission to the State;
2. The physician’s verbal orders for home care have been received and documented;
3. A plan of care has been established and sent to the physician; and
4. The first service visit under that plan has been delivered.

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Four Types of RAP Submissions

1. Initial episode RAP
2. Subsequent episode RAP
3. Transfer RAP
4. Discharge/readmit RAP

IF…	THEN…
The beneficiary is a new admission to the HHA, with no previous admissions to home health care within the last 60 days	This is an initial episode RAP The statement from and through date, the admit date, and the HIPPS code service date will match and will reflect the first Medicare billable service date. Use the appropriate source of admission code
The beneficiary is an existing patient with the HHA and is continuing care into a subsequent 60-day episode	This is a subsequent episode RAP The statement from and through date must be the first calendar day of the subsequent 60-day episode. There should not be a gap of days between episodes. The admit date will remain the original start of care date. The HIPPS code service date may be different than your statement from date because it has to be the first billable service date of the episode, which might not occur on the first calendar day of this subsequent episode. Use source of admission code “1”.
The beneficiary is a new admission to the HHA, with a previous admission to another HHA within the last 60 days (e.g., transfer to an agency from another)	This is a transfer RAP Verify if an open episode exists via the HIQH eligibility screens. If so, contact the agency with the open episode to verify the transfer. The statement from and through date, the admit date and the HIPPS code service date will match and reflect the first medically billable service date by the receiving agency. Submit RAP with condition code 47.
The beneficiary is a readmission to the HHA within the same 60-day episode	This is a discharge/readmit RAP The statement from and through date, the admit date, and the HIPPS code service date will match, and will reflect the first Medicare billable service date after the readmission to your receiving agency. Submit RAP as you would for any other home health episode.

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RAP Cancels

Requests for anticipated payment cannot be adjusted; however, an erroneous RAP can be canceled, which removes the episode in HIQH. The RAP can be canceled only if the final claim has not been submitted/processed.

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Different RAP Cancels Cause Different Outcomes

Requests for anticipated payment can be canceled by the provider, auto-canceled by the MAC, or canceled by a final claim.

Type of RAP Cancel	Outcome
Auto-cancel RAP	Occurs when claim not submitted within timeframe—done by the RHHI Type of bill (TOB) 328 Adjustment reason code field on claim page three will have “NF” Takes back RAP payment Does not remove episode from HIQH
RAP cancel	Occurs when RAP is canceled by provider TOB 328 Takes back RAP payment Removes episode from HIQH
Remittance take-back	Occurs when claim is submitted and processed FISS will show a cancel date on the RAP that will match the process date on the claim Remittance statement of claim—will also show RAP TOB 328 Takes back RAP payment, reissues total payment on the same remittance statement