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Selecting the Type of Bill for RAPs and EOEs

by Mark Nowlen

Occasionally, we receive questions from Kinnser customers regarding the Type of Bill (TOB) to use for a Request for Anticipated Payment (RAP) or an End of Episode (EOE) claim. The Type of Bill field indicates the type of bill for the purposes of third party processing of the claim. Code structure for the Type of Bill is a 3-digit alphanumeric code providing three specific pieces of information:

First Digit: identifies the type of facility.
*Technically, the first digit is a leading zero, but the leading zero should not be reported on electronic claims.

Available Codes for Type of Facility:

1 Hospital
2 Skilled Nursing
3 Home Health
4 Religious Non-Medical (Hospital)
7 Clinic or Renal Dialysis Facility (requires special information in second digit below)
8 Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)

Second Digit: classifies the type of care.

Available Codes for Type of Classification (if first digit is 1-5):
1 Inpatient (Part A)
2 Hospital-Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)
3 Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)
4 Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for "nonpatients")
8 Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)

Third Digit: referred to as a "frequency" code; indicates the sequence of this bill in this particular episode of care.

Available Codes for Frequency:
0 Nonpayment/zero claims
1 Admit Through Discharge Claim
2 Interim - First Claim
3 Interim - Continuing Claims (Not valid for PPS bills. Exception: SNF PPS bills)
4 Interim - Last Claim (Not valid for PPS bills. Exception: SNF PPS bills)
5 Late charge
7 Correction
8 Void/Cancel
9 Final Claim for a Home Health PPS Episode


Codes for Home Health Medicare Claims

First Digit - Type of Facility:
"3" - Home Health

Second Digit - Classification (if first digit is 1-5):
"2" - Hospital-Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)

For home health Medicare claims, bill the first two digits as "32". While the bill classification (second digit) of "3", defined as "Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)" may also be appropriate to an HH PPS claim, Medicare encourages HHAs to submit all claims with a bill classification of "2". Medicare claims systems determine whether a HH claim should be paid from the Part A or Part B trust fund and will change the bill classification digit on the electronic claim record as necessary to reflect this determination.

Third Digit - Frequency:
"2" - Interim - First Claim
HHAs use this code for the first of an expected series of payment claims for the same home health Start of Care.

"7" - Correction (Correction/Adjustment to a prior claim)
Replacement of Prior Claim - HHAs use this code 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
HHAs use this code to indicate this bill is an exact duplicate of an incorrect bill previously submitted. A replacement RAP or claim must be submitted for the episode to be paid.

"9" - Final Claim for a Home Health PPS Episode
This code indicates the HH bill should be processed as a debit/credit adjustment to the RAP. This code is specific to home health and does not replace frequency codes "7" or "8".

Codes for Home Health Managed Care Claims

Code selection is different for Managed Care claims, and unlike Medicare claims, you must select the correct Classification for the type of care. The Codes you will use for Managed Care claims are 331, 333 or 334:

First Digit - Type of Facility:
"3" - Home Health

Second Digit - Classification (if first digit is 1-5):
"3" - Outpatient

Third Digit - Frequency:
"1" - Admit Through Discharge Claim
"2" - Interim - First Claim
"3" - Interim - Continuing Claims (Not valid for PPS bills. Exception: SNF PPS bills)
"4" - Interim - Last Claim (Not valid for PPS bills. Exception: SNF PPS bills)

For more information, review Chapter 10, pp 218-220, of the Medicare Claims Processing Manual at https://www.cms.gov/manuals/downloads/clm104c01.pdf

Read more in: Billing

About Kinnser software

Kinnser Software, Inc. provides web-based solutions that deliver clinical and business results to the home health, hospice and private duty industries. Founded in 2003 and headquartered in Austin, Texas, Kinnser Software serves more than 4,000 home health, therapy, hospice, and private duty home care providers nationwide. Kinnser helps thousands of clinicians and other staff in post-acute healthcare to manage scheduling, billing, electronic visit verification, day-to-day operations, and patient referrals. 

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