Late RAP Penalty Adjustments for Home Health


For CY 2021, there will be a non-timely submission payment reduction when the HHA does not submit the RAP within 5 calendar days from the start of care date for the first 30-day period of care in a 60-day certification period. There will also be a non-timely submission payment reduction within 5 calendar days of the ‘from date” for the second 30-day period of care.

This reduction in payment will be equal to 1/30th the wage. The case-mix is adjusted for the 30-day period payment amount for each day from the HH start of care date/admission date or the “from date” for subsequent 30-day periods, until the date the HHA submits the RAP. The 1/30th reduction would be to the 30-day period payment amount, including any outlier payment that the HHA otherwise would have received absent any reduction.

For Low Utilization Payment Adjustment (LUPA) 30-day periods of care in which an HHA fails to submit a timely RAP, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. The payment reduction cannot exceed the total payment of the claim. The payment reduction for the late submission of a RAP can be waived for exceptional circumstances as outlined in regulations at 42 CFR 484.205(i)(3).

MACs will accept the KX modifier when reported with the Health Insurance Prospective Payment System (HIPPS) code on the revenue code 0023 line of Type of Bill (TOB) 032x (other than 0322 and 0320) as an indicator that an HHA requests an exception to the late RAP penalty. The HHA should provide sufficient information in the Remarks section of its claim to allow the MAC to research the exception request. If the remarks are not sufficient, the MAC will request documentation from the HHA. The four circumstances that may qualify the HHA for an exception to the consequences of filing the RAP more than 5 calendar days after the HH period of care from date are as follows:

1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA’s ability to operate

2. An event that produces a data filing problem due to CMS or MAC systems issue that is beyond the control of the HHA

3. A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC

4. Other circumstances determined by the MAC or CMS to be beyond the control of the HHA.

If the RAP that corresponds to a claim was originally received timely, but the RAP was canceled and resubmitted to correct an error, enter remarks to indicate this condition (for example, “Timely RAP, cancel and rebill”). Append modifier KX to the HIPPS code reported on the revenue code 0023 line. HHAs should resubmit corrected RAPs promptly (generally within 2 business days of canceling the original RAP).

HCHB late RAP Penalty Auto Calculation Adjustments

With the 5/11/21 release, agencies will have the option to set up an auto calculation adjustment for late RAP submissions. HCHB will run a nightly process to identify periods where the RAP was submitted outside the 5-calendar day deadline and will automatically calculate and apply the penalty adjustment.

To take advantage of this new functionality, agencies will need to create new adjustment codes for LATE RAP PENALTY and LATE RAP PENALTY OFFSET or select existing codes to be applied within the payor source setup.

In Payor Source Setup, enter the following within all appropriate payors.

Once completed, HCHB will adjust all appropriate accounts during the nightly process. Any previously applied contractual adjustments will be offset and reapplied at the newly calculated gross episodic amount.

Recommendations Prior to Auto Adjustment Setup

It is important to note that agencies must review the RAP console and make any necessary updates prior to setting up the auto calculation adjustment to avoid erroneous adjustments.

RAPs are often cancelled within HCHB to allow for changes to visit times. For example, if the 837 box is selected during this process but the claim is not actually submitted to the payor since no actual change is being made, HCHB will view this as a truly cancelled RAP. Once recreated, the new submission date will be used to calculate a RAP penalty unless a penalty override is entered.

Within the RAP console, timely submitted RAPs fall off the screen. All RAPs that remain on the screen are considered untimely and will be subject to adjustment unless the penalty override is entered. Once a penalty override is entered, a Y will appear in the Penalty Override column.

Since the functionality for auto adjustment calculation has not existed, billing staff may not have entered penalty overrides unless they were truly applicable for a RAP that is being submitted to the payor. This additional step will be required if the agency chooses to enable the new functionality.

It is recommended that agencies trend requests for billing staff to cancel/recreate claims within HCHB that are not related to actual changes that need to be submitted to the payor. Agencies should make every effort to prevent this practice as much as possible.

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