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Provider Handbook
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Previous Page Table of Contents Next Page
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Skilled Nursing Facility Pricing
Home Health Agency Pricing
Tips for Filing a Request for Anticipated Payment (RAP)
Tips for a Final Claim
Exceptions |
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Skilled Nursing Facility Pricing |
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SNFs are paid using the Medicare Prospective Payment System (PPS) and consolidated billing. SNF PPS rates cover all routine, ancillary, and capital costs of covered SNF services. SNFs are required to perform resident assessments using the Minimum Data Set (MDS). SNF admissions require an authorization when TRICARE is the primary payer. Children under age 10 and critical access hospital (CAH) swing beds are exempt from SNF PPS and are reimbursed based on DRG or contracted rates. For additional details on SNF PPS, refer to Chapter 8, Section 2 of the TRICARE Reimbursemnt Manual. |
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Home Health Agency Pricing |
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TRICARE pays Medicare-certified home health agencies (HHAs) using a payment system modeled on Medicare’s plan. Medicare-certified billing is handled in 60-day care episodes, allowing HHAs to receive two payments of 60 percent and 40 percent, respectively, per cycle. This two-part payment process is repeated with every new cycle, following the patient’s initial 60 days of home health care.
All home health services require prior authorization from Humana Military and renewal every 60 days. In order to receive private duty nursing or additional nursing services/shift nursing, the TRICARE beneficiary must be in the Custodial Care Transition Program (CCTP), and a case manager must manage his or her progress.
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Tips for Filing a Request for Anticipated Payment |
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- The bill type in Form Locator (FL) 4 of the UB-04 is always 322 or 332.
- The “To” date and the “From” date in FL 6 must be the same, and must match the date in FL 45.
- FL 39 must contain code 61 and the Metropolitan Statistical Area (MSA) code of the beneficiary.
- There must be only one line on an (RAP), and it must contain revenue code 023 and zero dollars. On this line, FL 44 must contain the Health Insurance Prospective Payment System (HIPPS) code. The quantity in FL 46 must be 0 or 1.
- FL 63 must contain the 18-digit authorization code assigned by the Outcome Assessment Information Set (OASIS).
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Note: This is not Humana Military’s prior authorization number. The 18-digit number contains the start date of the episode of care (first eight numbers), the date the assessment was completed (middle eight numbers), and the reason for the assessment (last two numbers). |
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Tips for a Final Claim |
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- Network home health providers must submit TRICARE claims electronically. The bill type in FL 4 must always be 329 or 339.
- In addition to the blocks noted for the RAP above, each actual service performed must be listed on the claim form lines. The dates in FL 6 must be a range from the first day of the episode plus 59 days. Dates on all the lines must fall between the dates in FL 6.
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Exceptions |
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- Providers designated as Corporate Services Providers (CSPs)* are exempt from the new claim-filing rules and may continue billing as always (fee for service).
- Beneficiaries enrolled in the CCTP are exempt from the new claim-filing rules and may continue billing as always (fee for service).
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*The CSP Class consists of freestanding corporations and foundations that render professional, ambulatory, in-home care, or technical diagnostic procedures. Typically, HHAs that qualify for CSP are pediatric home health agencies. HHAs designated as a CSP are exempt from the PPS billing rules. Those HHAs that are reimbursed under the Medicare PPS should continue billing under the guidelines of PPS. |
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