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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 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 40.1. 
 
The rules say that the Type of Bill is a 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 
period of care. The types of bill accepted for HH PPS claims 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 claim must be submitted for the period 
of care to be paid. 9 - Final Claim for an HH PPS Period - This code indicates an HH original bill to be processed 
following the submission of an HH PPS Notice of Admission (TOB 032A) 
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."A/B MACs (HHH) 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
04, 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 Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 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.