HHA PPS Claims Calculator

The Balanced Budget Refinement Act of 1999 requires each Medicare home health agency to be paid on the basis of a prospective payment amount. To assist home health providers in determining reimbursement for Medicare home health PPS claims, Palmetto GBA offers providers the ability to estimate their claims payment amount online. The online calculator is designed to estimate the amount of reimbursement for all types of Medicare home health agency (HHA) claims with service periods beginning on or after October 1, 2000. Effective 2007, the Deficit Reduction Act (DRA) requires Home Health providers to submit Required Quality Data in order to receive full reimbursement for episode payments in the current year and thereafter. For those providers who have not submitted the required data, episode payments will be reduced 2 percent. The PPS refinements effective January 1, 2008 include the elimination of the SCIC episode, an add-on for the non-routine supplies (NRS) based on clinical severity level, and an add-on for the initial LUPA episode.

In order to estimate the claims reimbursement you will need to know the following information:
  • Core Based Statistical Area (CBSA) code for the county in which the services are provided (MSA codes for services prior to 2007)
  • Home Health Resource Group (HHRG)/Health Insurance Prospective Payment System (HIPPS) weights
  • Required Quality Data has been reported (Y/N)
  • NRS Severity Level (1-6)
  • Initial or only LUPA episode (Y/N)
  • Number of days of care by initial HHA (PEPs only)

Claims Calculator

*If you do not know the MSA code or CBSA code that represents the location from which the services were rendered, you can find it while in the calculator by entering the state and selecting the county. If the county from which the services were rendered is not listed you should select Non-MSA or All Other Counties.

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