US · guidance

CMS Pub. 100-04, ch. 10, § 10.1.3

Configuration of the HH PPS Environment

activein force · 2026-08-25 – presentas-observed

The configuration of Medicare home health claim processing is similar to previous

Medicare claims processing systems. The flow from the HHA at the start of billing, to

the receipt or remittances and electronic funds transfer (EFT) by the agency, to the

recording of payment in either billing or accounting systems (bill/acct software) can be

envisioned as follows:

CWF

SS/Contractor

Front End

SS/Contractor

Back End

PRICER PS&R

Grouper

Billing

Software

Bank

Bill./

Acct.

Software

At HHA

At Contractor

At CWF Host

Inquiries

RAP/Claim Batches

Inquiries

Claims

EFT Payment

Remittances

Checks

RAPs

Subsystems, also known as drivers or software applications or modules, have been

created for HH PPS for Medicare home health claims processing.

• Grouper determines HHRGs for claims at HHAs by inputting OASIS data.

(OASIS is the clinical data set that currently must be completed by HHAs for

patient assessment.) OASIS software was updated to integrate the Grouper from

the advent of HH PPS, and CMS has made Grouper specifications available on its

Web site for those designing their own software.

• ELGH is an inquiry system in CWF available via A/B MAC (HHH) remote

access, through which HHAs and other providers can ascertain if a home health

episode has already been opened for a given beneficiary by another HHA, and

track episodes of beneficiaries for whom they are the primary HHA. HHAs may

also access this information via the HIPAA Eligibility Transaction System or

HETS. Refer to §§30.1 and 30.2 for a detailed description.

Pricer software is used to process all HH PPS claims and is integrated into the Medicare

claims processing systems. In addition to pricing HIPPS codes for HHRGs, this software

maintains national standard visit rate tables to be used in outlier and LUPA

determinations. Refer to §70 for a detailed description of the Pricer software.

History

(Rev. 2230, Issued: 05-27-11, Effective: 08-28-11, Implementation: 08-28-11)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: acd77c69d9df7e8559a44f882ce4dbfec9d7e3792322f31d9ce31dcc156dc80b

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