Medicare home health billing follows a fixed structure. If you know how the periods are built, what has to be in place before a claim leaves, and which deadlines are firm, most billing problems become easier to see before they happen. This guide covers Original Medicare. It is general education, not legal or billing advice for your agency.
How Original Medicare organizes payment
Medicare pays home health agencies a set amount for each 30-day period of care. That payment unit has applied since 2020 (42 CFR 484.205). A patient can receive an unlimited number of periods, but they cannot overlap, and a period can be shorter than 30 days, for example after a transfer or a discharge and readmission.
Certification works on a different clock. A physician or allowed practitioner certifies eligibility at the start, and must recertify at least every 60 days if care continues (42 CFR 424.22). In practice, one 60-day certification period contains two 30-day payment periods, and each 30-day period is billed with its own claim.
What must be in place before a claim goes out
A claim is only as strong as the clinical record behind it. Under Medicare's rules, the patient needs intermittent skilled care, must be homebound, must be under the care of a physician or allowed practitioner, and must have a plan of care. The Medicare program describes the patient-facing version of these requirements on its home health services page. Three items deserve special attention:
- Certification. The physician or allowed practitioner must certify the patient's eligibility, and the medical record must support it.
- Face-to-face encounter. The encounter must be related to the main reason the patient needs home health care. It must happen no more than 90 days before the start of care or within 30 days after it, and the certifying practitioner must document its date. Telehealth can qualify if it meets Medicare's telehealth rules.
- Comprehensive assessment. It must be completed no later than 5 calendar days after the start of care (42 CFR 484.55). Medicare also needs the assessment to be accepted in its quality reporting system before the claim arrives. A claim that cannot be matched to an accepted assessment is returned.
The practitioner who orders or certifies the care must also be enrolled in Medicare in an approved status (or have validly opted out), and be identified on the claim by legal name and National Provider Identifier (42 CFR 424.507).
Check who is actually the payer
Verify coverage before the first visit and again as care continues. If a patient is enrolled in a Medicare Advantage plan, that plan, not Original Medicare, is the payer. The Medicare Claims Processing Manual says that if a patient on Original Medicare enrolls in a Medicare Advantage plan during a period of care, the period ends and is paid proportionally, and the plan becomes the primary payer on its enrollment date (Claims Processing Manual, chapter 10). Only one agency can be the primary agency for the same admission period, unless the situation is a transfer or a discharge and readmission.
The notice of admission
At the start of care, the agency must send Medicare a notice of admission, and have it accepted, within 5 calendar days after the start of care date. It is a one-time submission that covers the following 30-day periods until the patient is discharged from Medicare home health services. A new one is needed after a discharge.
If it is late, the payment for the 30-day period is reduced by one thirtieth for each day from the start of care until the notice is accepted. Those days are the agency's liability, and the patient must not be billed for them. CMS can waive the consequence in certain circumstances beyond the agency's control, but the agency must document them (42 CFR 484.205(j)). Because the deadline is short and the cost grows each day, this is the item to put on a calendar the day an admission happens.
When the claim is submitted
Payment for a period is requested with a claim submitted at the end of the 30-day period, or after discharge if that comes first. Medicare's manual says the agency may not submit it until all services for the period are provided and the physician has signed the plan of care and any later verbal orders.
What happens after submission
Receiving a claim and deciding on payment are separate steps. First, the claim is accepted or returned for correction. Then Medicare processes it and issues a payment decision, which is explained on the remittance advice.
Medicare also builds in a waiting period. For a clean claim submitted electronically in the standard format, the earliest day payment can be made is the 14th day after it was received. A payment on that day is not guaranteed, only the earliest it can happen. See Claims Processing Manual, chapter 1.
The filing deadline
Medicare generally requires claims to be filed within 12 months of the date of service. For home health claims, which show a span of dates, the through date on the claim starts that clock. A claim that arrives later is denied for untimely filing, with limited exceptions (same chapter).
What the agency owns and what can be delegated
Some responsibilities stay with the agency, whoever does the billing:
- Clinical judgment, including homebound status, the plan of care and the assessment.
- Obtaining signed certifications, orders and the face-to-face documentation from practitioners.
- Telling the billing team promptly about admissions, start-of-care dates, discharges and any change in a patient's coverage.
- Responsibility for what is submitted under the agency's Medicare enrollment.
A billing company can take on the administrative work: preparing claims, checking them against the information it has before submission, sending the notice of admission on time, following claims after they go out, and tracking payments and remittance advice so open items get an owner. Write the split into the agreement, as described in our guide to choosing a billing company.
Related guides
See why home health claims come back for what to do when a claim is returned, rejected or denied, and choosing a home health billing company for questions to ask before you hire help.