CMS Requires HIPPS and Rate Codes for Skilled Nursing Facilities and Home Health Agencies Claims — Effective July 1, 2014

Date Issued: 7/17/2014

As mandated by the Centers for Medicare & Medicaid Services (CMS), beginning July 1, 2014, skilled nursing facilities and home health agencies must include all applicable Health Insurance Prospective Payment System (HIPPS) and rate codes for claims involved in Risk Adjustment Processing System (RAPS) reporting.

These codes, specifically Resource Utilization Groups (RUGs) and Home Health Resources Groups (HHRGs) identify and represent specific sets of patient characteristics (or case-mix groups). CMS uses this information for payment determination.

For EmblemHealth, this information impacts Medicare reimbursement via the RAPS reporting (CMS Encounter Data System) process. If HIPPS codes are not included in the claims submissions, the claim will be denied.