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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 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 30-day period of care. HHAs submit an NOA at the beginning of an 
admission and then submit one claim for each 30-day period of care. Claims submitted before an NOA has 
been received for the beneficiary will be returned to the provider. 
Billing Provider Name, Address, and Telephone Number 
Required  The HHAs minimum entry is the agencys name, city, state, and ZIP Code. The post office box 
number or street name and number may be included. The state may be abbreviated using standard post office 
abbreviations. Five or nine-digit ZIP Codes are acceptable. A/B MACs (HHH) use this information in 
connection with the provider identifier to verify provider identity. 
Patient Control Number and Medical/Health Record Number 
Required - The patients control number may be shown if the patient is assigned one and the number is needed 
for association and reference purposes. 
The HHA may enter the number assigned to the patients medical/health record. If this number is entered, the 
A/B MAC (HHH) must carry it through their system and return it on the remittance record. 
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 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 information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
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.