Home Health Billing

PDGM 30-day periods, Notices of Admission and LUPA awareness — home health billing for Medicare-certified agencies.

Home health billing under Medicare's Patient-Driven Groupings Model (PDGM) has almost nothing in common with office-based billing: payment is by 30-day period, driven by admission source, timing, clinical grouping and functional level from OASIS — and a single late notice can zero out a period's payment. Elite Bill Care's home health billing service is built for Medicare-certified agencies operating under these rules.

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Home health billing specifics

Notice of Admission (NOA) — submitted within five calendar days of the start of care; late NOAs reduce payment day-for-day, so submission discipline is revenue protection, not clerical work.
30-day period claims — each period billed with the correct HIPPS code from the grouping (admission source × timing × clinical group × functional level × comorbidity adjustment).
LUPA thresholds — periods falling below the visit threshold for their group are paid per-visit instead of the full period rate; visit tracking against thresholds during the period is where agencies protect the difference.
OASIS accuracy — functional scoring on OASIS directly sets the payment group; billing review flags mismatches between OASIS responses, the plan of care and visit notes before claims go out.
Face-to-face and certification — encounter documentation and physician certification/recertification requirements tracked per episode, because their absence voids payment regardless of care quality.
Medicare Advantage and Medicaid — MA plans increasingly mirror PDGM-like authorization and period rules with their own variations; verified plan by plan.

How we run it

Admissions enter a period calendar on day one: NOA filed, period end dates set, visit counts monitored against LUPA thresholds, and final period claims submitted with HIPPS verified against OASIS and the plan of care. Denied or returned claims (RTP) are worked through denial management with the clinical documentation assembled. See our billing services for the wider operation.

Frequently asked questions

Do you bill for home health under PDGM only, or other payers too?

Medicare PDGM is the core; we also bill Medicare Advantage and Medicaid home health programs under their plan and state rules.

Can you help with RAP-era cleanup or old outstanding periods?

Yes — reviewing unbilled or returned periods and aged home health AR is a standard starting engagement; see AR management.

Do you handle hospice billing?

Hospice operates under its own benefit and NOE (Notice of Election) rules — a related but distinct service. Ask us about your situation and we will be direct about fit.