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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare pays for home health care services under a prospective payment system (HH PPS). Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set (OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the Medicare Claims Processing Manual, Chapter 10, Section 40.1. The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. You can find this rule and detailed instructions for the claim in the Medicare Claims Processing Manual, Chapter 10, Section 40.2. Type of Bill Required - This 4-digit alphanumeric code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are: 032x - Home Health Services under a Plan of Treatment 4th Digit - Definition 7 - Replacement of Prior Claim - HHAs use to correct a previously submitted bill. Apply this code for the corrected or "new" bill. These adjustment claims must be accepted at any point within the timely filing period after the payment of the original claim. 8 - Void/Cancel of a Prior Claim - HHAs use this code to indicate this bill is an exact duplicate of an incorrect bill previously submitted. A replacement RAP or claim must be submitted for the episode to be paid. 9 - Final Claim for an HH PPS Episode - This code indicates the HH bill should be processed as a debit/credit adjustment to the RAP. This code is specific to home health and does not replace codes 7, or 8. HHAs must submit HH PPS claims with the 4th digit of "9." These claims may be adjusted with code "7" or cancelled with code "8." Medicare contractors do not accept late charge bills, submitted with code "5," on HH PPS claims. To add services within the period of a paid HH claim, the HHA must submit an adjustment. You can find this rule in the Medicare Claims Processing Manual Chapter 10, Section 40.2. The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid
information for all of these elements may be returned as unprocessable. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.