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Patient-Driven Groupings Model for Home Health Agencies

Monday, April 27, 2020

The Defense Health Agency (DHA) has updated the TRICARE manuals to include a Patient-Driven Groupings Model (PDGM) for home health agency reimbursement. TRICARE’s PDGM reimbursement is effective retroactive to Jan. 1, 2020, for periods of care that begin on or after Jan 1. Health Net Federal Services, LLC (HNFS) will release PDGM-reimbursed home health agency (HHA) claims with dates of service on or after Jan. 1 as soon as system changes are implemented; however, we do not yet have an estimated completion date. 

TRICARE’s PDGM reimbursement model closely follows Medicare’s PDGM.

  • Reimbursement is based on 30-day periods of care vs. 60-day episodes.
  • Therapy thresholds are no longer used to determine payments; rather, reimbursement is based on timing, admission source, clinical group, functional impairment level, and comorbidity adjustment.
  • Health Insurance Prospective Payment System (HIPPS) codes are still reported with revenue code 0023.

Unlike Medicare’s PDGM model, TRICARE still requires providers to submit a Treatment Authorization Code (TAC).   

Authorizations for home health services, OASIS assessments and updates to patient care plans remain on a 60-day basis.

Except for low utilization home health agencies, providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim. Providers must bill in non-overlapping 30-day periods of care.

  • For 60-day episodes that began on or before Dec. 31, 2019 and span into 2020, payment will be for the 60-day episode. For 30-day periods of care that start on our after Jan. 1, 2020, reimbursement is based on 30-days.  
  • HHAs participating in Medicare prior to Jan. 1, 2019 will continue to receive RAP payments, now a 20/80 split. Those who began participating in Medicare on or after Jan. 1, 2019 will receive an entire payment with the final claim. 
  • HHAs with low utilization (2–6 visits per 30-day period) will be paid a standardized per visit payment instead of payment for a 30-day period of care.  

Medicare updates rates annually on a calendar year (CY) basis. 

Review our billing tips for additional details.

Note: This guidance does not apply to home health services provided to active duty family members under the Extended Care Health Option (ECHO).