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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 home health agencies (HHAs) may not submit a claim until after all services are provided for 
the period and the physician has signed the plan of care and any subsequent verbal order. You can find this rule 
in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing Manual, Chapter 
10, Section 10.1.10.4. 
 
Since 1999, Home Health Agencies (HHAs) have been required by Medicare to assess potential patients, and 
reassess existing patients, incorporating the OASIS (Outcome and Assessment Information Set) tool as part of 
the assessment process. The total case-mix adjusted payment is based on elements of the OASIS data set and 
other information provided on the claim. Payments made for the period are case-mix adjusted based on 
Grouper run in Medicare systems. Pricer software run by the A/B Medicare Administrative Contractor (MAC) 
(Home Health and Hospice (HHH)) processing home health claims performs pricing including wage index 
adjustment and other factors. 
 
Submission of an OASIS assessment is a condition of payment for HH periods of care. OASIS reporting 
regulations require the OASIS to be transmitted within 30 days of completing the assessment of the 
beneficiary. Under the HH Patient-Driven Groupings Model (PDGM), matching a claim to the OASIS 
assessment is more important than ever. 
 
During claims processing, the quality system, known as the Internet Quality Improvement and Evaluation 
System (iQIES), provides the claims system (Fiscal Intermediary Standard System (FISS)), with the OASIS 
items used for payment grouping under the PDGM. The Health Insurance Prospective Payment System 
(HIPPS) code is calculated by Medicare's Grouper program with FISS. Because payment grouping cannot 
occur without the OASIS information, if the OASIS assessment is not found in the quality system upon receipt 
of a claim, Medicare systems will return the HH claim. 
 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, Sections 10.1.6 and 10.1.19. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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.