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Latest RAP-related claims error involves placeholder HIPPS code

Some agencies are facing new payment issues related to the no-pay RAPs that began January 1, 2021.

MACs Palmetto GBA and CGS, collectively responsible for claims in 31 states, have recently alerted agencies to a potential issue where Medicare’s system is sometimes not replacing the placeholder HIPPS code used to match RAPs and final claims.

Since the implementation of PDGM, a system-calculated HIPPS code has been used for final payment instead of the HIPPS code provided by the agency on the final claims. Now, agencies are learning that the HIPPS code is not getting replaced on some claims.

This is a particular issue this year because CMS has told agencies that any generic HIPPS code would be acceptable on the final claim, as long as it matched a generic code provided on the RAP. In some cases, agencies have been using the same HIPPS code for all RAPs and final claims.

Palmetto GBA has told agencies that no action is necessary. Providers should not cancel claims or RAPs to address the issue, they said.

Agencies should continue to monitor guidance from their Medicare Administrative Contractors on the latest claims issues.