Skilled Nursing Facility Pricing
Skilled nursing facilities (SNFs) are paid using the Medicare 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 . 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 Reimbursement Manual.
Home Health Agency Pricing
TRICARE pays Medicare-certified home health agencies (HHAs) using a PPS 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 60-day 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 may be enrolled in an alternative TMA-approved special program and a case manager must manage his or her progress.
Tips for Filing a Request for Anticipated Payment (RAP)
To file a request for anticipated payment (RAP):
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The bill type in Form Locator (FL) 4 of the UB-04 is always 322 or 332.
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The “To” date and the “From” date in FL 6 must be the same, and must match the date in FL 45.
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FL 39 must contain code 61 and the Core-Based Statistical Area (CBSA) code of the beneficiary’s residence address.
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There must be only one line on the 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.
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FL 63 must contain the authorization code assigned by the Outcome Assessment Information Set (OASIS). Note: This is not Humana Military’s prior authorization number.
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.
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In addition to the blocks noted for the RAP above, each actual service performed with the appropriate revenue code must be listed on the claim form lines. The claim must contain a minimum of five lines in order to be processed as a final RAP. 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.
Exceptions
Providers designated as Corporate Services Providers (CSPs)* are exempt from the new claim-filing rules and may continue billing as always (fee for service).
*The CSP Class consists of freestanding corporations and foundations that render professional, ambulatory, or 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. HHAs that are reimbursed under the Medicare PPS should continue billing under the guidelines of PPS.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Pricing
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) prices are established by using the Medicare fee schedules, reasonable charges, state prevailing rates, or average wholesale pricing. Most payments of durable medical equipment (DME) are based on the fee schedule established for each DMEPOS item by state. The services and/or supplies are coded using CMS Healthcare Common Procedure Coding System (HCPCS) Level II codes that begin with the letters:
- A (medical and surgical supplies)
- B (enteral and parenteral therapy)
- E (DME)
- K (temporary codes)
- L (orthotics and prosthetic procedures)
- V (vision services)
Inclusion or exclusion of a fee schedule amount for an item or service does not imply TRICARE coverage or non-coverage.
In addition to the DMEPOS schedule, parenteral and enteral nutrition items and services and fees are also included. DMEPOS pricing information is available at Noridian's Web site.
Home Infusion Drug Pricing
Home infusion drugs are reimbursed at the lesser of the billed amount or 95 percent of the average wholesale price (AWP).
Home infusion drugs are those drugs (including chemotherapy drugs) administered by means other than oral means, e.g., the drug must be administered either intramuscularly, subcutaneously, intravenously, or infused through a piece of DME. DME verification is not required.
Claims for home infusion will be identified by the place of service and the CMS HCPCS National Level II Medicare codes along with the specific National Drug Code (NDC) number of the administered drug. The TRICARE-allowable charge for these drugs will be determined and reimbursed at the lower of the billed charge or 95 percent of the AWP, as retrieved from the National Drug Data File (formerly the National Drug Blue Book).
Modifiers
Providers should use applicable modifiers that fit the description of the service, and the claim will be processed accordingly. The CPT and HCPCS publications contain lists of modifiers available for describing services. If a provider believes a claim was incorrectly denied, the provider should follow the allowable charge review process explained under “TRICARE Claim Appeals/ Reconsiderations” in the Claims Processing and Billing Information section of this handbook.
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