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Medical billing / Field guide

Check the record before the claim.

A Medicare home-health billing review should make each unresolved question visible to its owner while there is still time to act. This is a working sequence for agency leaders and billing teams, not a substitute for the current CMS manual or payer instructions.

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Three clocks. One accountable record.

Home-health billing is not one deadline at the end of an episode. The Medicare FFS Notice of Admission must be accepted by the contractor within five calendar days of the start of care to be timely; PDGM pays by 30-day period; certification and plan-of-care review generally follow a 60-day cycle. The clinical record and accepted OASIS assessment have their own workflow.

That distinction matters. The older LUCA checklist referred to RAPs and a 60-day payment unit. CMS replaced RAPs with the NOA for admissions beginning in 2022, and the PDGM payment unit is 30 days. Those older instructions should not be reused.

This guide is limited to a review framework for Medicare FFS home health. Medicare Advantage, Medicaid, and commercial plans have their own contracts and processes. A qualified agency reviewer must decide what applies to an individual claim.

A practical pre-claim sequence

Six checks, each with an owner.

  1. 01

    Confirm the payer and the benefit

    Start with the actual coverage for the dates of service. Distinguish Original Medicare fee-for-service from a Medicare Advantage or other payer workflow before applying a Medicare FFS checklist. The eligibility and authorization record should identify who checked it, when, and which payer instructions govern the case.

  2. 02

    Put the clinical basis beside the claim

    Check that the record supports home-health eligibility, skilled need, the certifying physician or allowed practitioner, and a plan of care that is established and reviewed as required. A billing reviewer should flag a gap for clinical resolution—not rewrite a clinician's assessment or manufacture a diagnosis.

  3. 03

    Track the Notice of Admission

    For Medicare FFS, the Notice of Admission replaced the Request for Anticipated Payment in 2022. CMS says the NOA is a one-time filing for an admission; to be timely, the Medicare contractor must accept it within five calendar days of the start of care. Track acceptance, not merely transmission, and keep any exception or correction trail with the account.

  4. 04

    Reconcile OASIS before final billing

    Use the applicable OASIS instrument and confirm the assessment was accepted in iQIES before the corresponding Medicare FFS claim. Compare the identifiers and assessment date used for claims-to-OASIS matching. An accepted file and a clinically accurate assessment are distinct checks; billing should not change clinical responses to make a claim pass.

  5. 05

    Watch the correct payment period

    Under the Patient-Driven Groupings Model, the Medicare FFS payment unit is a 30-day period, while certification and plan-of-care review generally follow a 60-day cycle. Do not treat those as the same clock. Check the applicable case-mix group, visits, and low-utilization payment adjustment threshold for the period and year in question.

  6. 06

    Resolve the exception before release

    Reconcile the claim with orders, visits, documented changes, diagnosis coding, payer responses, and any open documentation request. Assign each exception to the person who can actually resolve it. Record whether the claim was released, held, corrected, or sent for clinical review—and preserve the reason.

What a buyer should ask

Make the handoffs inspectable.

Ask a billing partner to show the owner and evidence for each checkpoint: the accepted NOA, the OASIS validation result, the period and LUPA check, the unresolved-exception queue, and the final claim release. Ask what happens when a clinician or payer must answer before billing can move forward.

A dashboard is not the same as a released claim or a recovered denial. Separate the labor scope, the software used to display the work, the agency's clinical decision rights, and the payer's final decision. Agree on access, responsibilities, fees, and protected-data handling before work begins.

Primary sources / checked September 2026

Verify the rule at its source.

CMS materials and payer instructions change. This guide is educational; it is not clinical advice, a coding determination, a coverage guarantee, or a legal opinion.

Where does your claim stop?

Tell us which payer, claim stage, and handoff needs attention—without sending patient information through this form. We can discuss the human billing scope and the evidence you would expect to see. Any engagement is defined in writing.

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