Billing PrimeWest Health

Providers must be familiar with Medicare coverage for members receiving home care. This includes billing Medicare when Medicare is liable for the service or, if the provider is not Medicare-certified, referring the member to a Medicare-certified provider of the member’s choice and notifying members when Medicare is no longer the liable payer for home care services.

Patient-Driven Grouping Model (PDGM)

The Centers for Medicare & Medicaid Services (CMS) finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. The PDGM relies on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds. PDGM includes a 30-day period episode. 

If the service is covered by Medicare, then Medicare guidelines must be followed. Refer to CMS PDGM guidelines for home care services covered by Medicare. This affects all dually eligible members (those members covered under a Medicare home health plan of care and who are on Medical Assistance [Medicaid]).

Medicare requires consolidated billing of all home health services while a Medicare recipient is under a home health plan of care. All supplies and services listed under the PDGM are the responsibility of the home health agency whose care the member is under during the Medicare PDGM episode and are not billable by other providers.

The principal diagnosis code on the home health claim assigns the home health period of care to a clinical group that explains the primary reason the patient is receiving home health services. 

The six home health disciplines included in the 30-day period payment rate are as follows:

1. Skilled nursing services
2. Home health aide services
3. Physical therapy
4. Speech-language pathology services
5. Occupational therapy services
6. Medical social services

The 30-day period payment rate also includes amounts for non-routine medical supplies and therapies that could have been unbundled from Part B prior to Home Health Prospective Payment System (HH PPS).

For 60-day episodes that begin on or before December 31, 2019, and end on or after January 1, 2020 (i.e., episodes that would span the January 1, 2020, implementation date), payment will be the CY 2020 national, standardized 60-day episode payment amount.

For home health periods of care that begin on or after January 1, 2020, the unit of payment will be the CY 2020 national, standardized 30-day payment amount.

Effective January 1, 2022, home health agencies may not submit Requests for Anticipated Payment (RAPs) Type of Bill (TOB) 322 for any home health period of care with a "From" date on or after January 1, 2022. Instead, for each admission to home health, the home health agency must notify Medicare/PrimeWest Health via submission of a Notice of Admission (NOA). The NOA can be sent by mail, electronic data interchange (EDI), or direct data entry.

For a transitional member, providers must complete and end their Medicare payment and then submit a new TOB 322 when PrimeWest Health is the primary payer.

Effective January 1, 2024, home health agencies may separately report disposable Negative Pressure Wound Therapy (dNPWT) devices on TOB 32x claims to receive separate payment by utilizing Healthcare Common Procedure Coding System (HCPCS) code A9272.

PW_11-19_553
Updated_12/24/2025