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HMO PART A - UNITED HEALTHCARE

Posted

HMO patient admitted on 8/4 discharged to hospital on 8/12, returned 8/14

entry 8/4, 5 day ard 4/10 , DRA ard 8/12 , entry 8/14, 5 day 8/20 & admission 8/20.

Also I had to open end of PPS assessment per our facility requirement ARD 8/12 (I just coded the assessment as Non-CMS assessment).

I am new with this company and I have never opened end of PPS for HMO patients , I am confused. I thought end of pps and interrupted stay are just for traditional Medicare.

Talino

Specializes in ER CCU MICU SICU LTC/SNF.

Correct, all PPS type assessments are only required for traditional Medicare.

For billing purpose, Med Advantage products (HMO, PPO, etc) require the HIPPS code in the claims (UB04) which can only be generated by a PPS assm’t.

The end of PPS is done by the SNF to notify the traditional Medicare contractor that the coverage has ended. It is not required by the HMOs since they determine end of coverage and retain that info themselves.

I’m assuming, rather than verify what each Med Advantage carrier requires, the facility just applies the PPS rules regardless.