RAP and Final Claim (Home Health)
RAP (Request for Anticipated Payment) and Final Claim are the two-step billing sequence for Medicare home health episodes under PDGM. RAP submitted within 5 days of SOC, Final Claim within 30 days of episode end.
Definition.
Home health billing under the Patient-Driven Groupings Model uses a two-claim sequence: Request for Anticipated Payment (RAP) at the start of each 30-day period and Final Claim at episode end. Missing windows trigger no-pay RAPs or auto-cancellation. Disciplined sequence management is foundational to home health revenue cycle.
Key points.
RAP timing
RAP must be submitted within 5 calendar days of Start of Care or recertification. Late RAP results in a no-pay RAP with payment penalty for late filing.
Final Claim timing
Final Claim must be submitted within 30 days of episode end (or for periods 60 days from start of period). Late Final Claim triggers payment reduction or denial.
OASIS timing
Comprehensive Assessment (OASIS-E) must be completed within 5 days of SOC. Resumption of Care OASIS within 48 hours of inpatient return. Follow-up OASIS at recertification.
LUPA thresholds
Periods with fewer than 5 visits convert to LUPA per-visit payment rather than full episode payment. Visit count below threshold creates significant revenue gap; above threshold preserves episode payment.
PDGM case-mix
PDGM case-mix is driven by admission source, episode timing (early vs late), clinical grouping, functional impairment, and comorbidity adjustment. Accurate OASIS coding drives case-mix and payment.