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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. 
 
Medicare guidance says the episode/period of care payment is specific to one individual homebound 
beneficiary. It pays all Medicare covered home care that is reasonable and necessary for the patients care, 
including routine and nonroutine supplies used by that beneficiary during the episode/period of care. It is the 
only Medicare form of payment for such services, with the exceptions described in Section 10.B. 
 
10.1.10 - Provider Billing Process Under HH PPS 
The next four sections describe the basic HH PPS billing process, not including payment adjustments. Payment 
adjustment follows in subsequent sections. 
10.1.10.3 - Submission of Request for Anticipated Payment (RAP) The HHA can submit a Request for 
Anticipated Payment, or RAP, to Medicare when all of the four following conditions are met. After the OASIS 
assessment is complete, locked or export ready, or there is an agency-wide internal policy establishing the 
OASIS data is finalized for transmission to the national assessment system; Once a physicians verbal orders 
for home care have been received and documented; A plan of care has been established and sent to the 
physician; and; The first service visit under that plan has been delivered. An episode/period will be opened on 
CWF with the receipt and processing of the RAP. HHAs should submit the RAP as soon as possible after care 
begins in order to assure being established as the primary HHA for the beneficiary. 
RAPs are submitted using TOB 0322. The HH Pricer software will determine the first of the two HH PPS split 
percentage payments, which is made in response to the RAP. See sections 10.1.12 and 40.1 for more details on 
RAPs. 
10.1.10.4 - Claim Submission and Processing HH claims must be submitted with TOB 0329. The HH PPS 
claim will include elements submitted on the RAP, and all other line item detail for the episode/period. 
An HH PPS claim with TOB 0329 is processed in Medicare claims processing systems as a debit/credit 
adjustment against the record created by the RAP. 
40.1 - Request for Anticipated Payment (RAP) In general, a RAP and a claim will be submitted for each 
episode or period of care. Each claim must represent the actual utilization over the episode period. While a 
RAP is not considered a claim for purposes of Medicare regulations, it is submitted using the same formats as 
Medicare claims. Statement Covers Period (From-Through) Required - Typically, these fields show the beginning and ending dates of the period covered by a bill. Since the RAP is a request for payment for future 
services, however, the ending date may not be known. The RAP contains the same date in both the from and 
through date fields. On the first RAP in an admission, this date should be the date the first service was 
provided to the beneficiary. On RAPs for subsequent episodes of continuous care, this date should be the day 
immediately following the close of the preceding episode or period. 
40.2  HH PPS Claims 
The following data elements are required to submit a claim under home health PPS. For billing of home health 
claims not under an HH plan of care (not under HH PPS), see 90. Home health services under a plan of care 
are paid based on a 60- day episode of care (before January 1, 2020) or a 30-day period of care (on or after 
January 1, 2020). Payment for this episode or period will usually be made in two parts. After a RAP has been 
paid and an episode or period has been completed, or the patient has been discharged, the HHA submits a claim 
to receive the balance of payment due. HH PPS claims will be processed in Medicare claims processing 
systems as debit/credit adjustments against the record created by the RAP, except in the case of No-RAP 
LUPA claims (see Section 40.3). As the claim is processed the payment on the RAP will be reversed in full and 
the full payment due for the episode will be made on the claim. Both the debit and credit actions will be 
reflected on the RA so the net payment on the claim can be easily understood. Statement Covers Period 
Required - The beginning and ending dates of the period covered by this claim. The from date must match 
the date submitted on the RAP for the episode. For continuous care episodes, the through date must be 59 
days after the from date for a 60-day episode or 29 days after the From date for a 30-day period of care. A 
medical necessity review was not completed as the denial was not for medical necessity. You can find the 
guidance in the Medicare Claims Processing Manual, Chapter 10  Home Health Agency Billing, Section 10.1 
 Home Health Prospective Payment System (HH PPS), Section 10.1.4  The HH PPS  Unit of Payment, 
Section 10.1.10  Provider Billing Process Under HH PPS, Section 10.1.10.3  Submission of Request for 
Anticipated Payment (RAP), Section 10.1.10.4  Claims Submission and Processing, Section 40.1  Request 
for Anticipated Payment (RAP) and Section 40.2 HH PPS Claims. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.