TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement

May 19, 2020

Retroactive to January 1, 2020, TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement. Humana Military will release PDGM-reimbursed HHA claims with dates of service on or after January 1 as soon as system changes are implemented.

TRICARE’s PDGM model

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. 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, TRICARE requires a Treatment Authorization Code (TAC).
**Authorizations for home health services, OASIS assessments and updates to patient care plans remain on a 60-day period of care.

Reimbursement

Except for low utilization HHAs, 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 December 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 January 1, 2020, reimbursement is based on 30-days.
  • HHAs participating in Medicare prior to January 1, 2019 will continue to receive RAP payments, now a 20/80 split. Those who began participating in Medicare on or after January 1, 2019 will receive an entire payment with the final claim.
  • HHAs with low utilization (two to six 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 basis.

Note: This guidance does not apply to home health services provided to Active Duty Family Members (ADFM) under the Extended Care Health Option (ECHO).