Call Vector Medical Billing
+1 (929) 539-7737
50States
Home Health Billing Services
Medicare pays home health agencies per 30-day period under the Patient-Driven Groupings Model (PDGM). Each period’s payment depends on a HIPPS code built from the OASIS assessment and the claim: period timing, admission source, clinical group, functional impairment, and comorbidities. The Notice of Admission is due within 5 calendar days of the start of care. If it is late, the period’s payment drops by 1/30 for every day from the start of care until it is filed.
98%Published NCR
24hClaim Submission
BAASigned with every client
AAPCCertified coders
AHIMACertified coders
E&OErrors and omissions insured
50 StatesRemote billing nationwide
30-day periods
What home health billing includes
One Notice of Admission per admission, then one claim per 30-day period.
The agency files a Notice of Admission (bill type 032A) when care starts, then a claim for each 30-day period (bill type 0329) after the period ends. PDGM groups each period by timing (early or late), admission source (community or institutional), one of 12 clinical groups from the primary diagnosis, a low, medium, or high functional impairment level from OASIS, and a comorbidity adjustment. Medicare regroups each claim from OASIS and claim data.
If a period has fewer visits than its group’s low-utilization payment adjustment (LUPA) threshold, between 2 and 6 visits, Medicare pays per visit instead of the period amount. For 2026, CMS recalibrated the case-mix weights and LUPA thresholds and estimates total home health payments 1.3% lower than in 2025.
What the home health fee covers
- NOA submitted within 5 calendar days of the start of care
- OASIS completed and accepted before the period claim is sent
- Primary diagnosis and comorbidity coding checked against the plan of care
- LUPA watch on visit counts before each period closes
Where home health claims lose money
PDGM pays for documentation and timing as much as for visits.
A late Notice of Admission
A late NOA reduces the period’s payment by 1/30 for every day from the start of care until it is submitted, so the first five days count too. An NOA filed 10 days after the start of care takes about a third off the period.
A primary diagnosis that does not group
If the primary diagnosis does not map to a PDGM clinical group, for example many symptom codes, the claim is returned. The primary diagnosis has to be the reason for home health.
Face-to-face and certification gaps
The face-to-face encounter must occur within 90 days before or 30 days after the start of care and relate to the primary reason for home health. From 2026, any allowed practitioner can perform it, even if not the certifying practitioner.
One visit short of the LUPA threshold
A period one visit below its threshold pays per visit, often a fraction of the period rate. Visit schedules are checked before the period closes.
OASIS and claim out of step
The functional impairment level comes from OASIS. If the assessment is late, not accepted, or does not match the claim, the period is returned or paid at a lower weight.
Medicare Advantage authorizations
Most Medicare Advantage plans require authorization for home health and pay under their own contract terms rather than PDGM rates. Authorization dates have to cover every visit billed.
Home health claim flow
Each step feeds the next. A late or missing one stops the period claim.
| Step | Rule | Claim or record |
|---|---|---|
| Start of care | OASIS start-of-care assessment completed within 5 days after the start of care | OASIS submitted to iQIES |
| Notice of Admission | Within 5 calendar days of the start of care; if late, 1/30 off for each day from the start of care until filed | Bill type 032A |
| Face-to-face encounter | Within 90 days before or 30 days after the start of care, related to the primary reason for home health | Documented with the certification |
| Each 30-day period | Claim after the period ends; PDGM grouping produces the HIPPS code | Bill type 0329 |
| Early and late periods | The first 30-day period of an admission groups as early; later periods group as late | Timing on the HIPPS code |
| LUPA check | Visit count below the group’s threshold pays per visit | Per-visit payment |
| Discharge or transfer | Patient status on the final claim; a transfer to another agency starts that agency’s NOA | Final period claim |
Agencies often work alongside: physical therapy · wound care · hospice · skilled nursing.
Not inside the monthly fee
The monthly cycle bills claims that are already in the system. These are scoped on their own.
Written rate
The fee is a percentage of net collections (flat or per claim in New York). No setup fee on the monthly cycle. Month to month. The written rate follows volume, payer mix, and how much of the cycle you hand over.
See pricing or request a written rate after the free audit.
Separate work
OASIS coding review, ADR and targeted probe responses, and Medicaid home care programs with their own billing systems are scoped on their own.
Audit NOA timing and LUPA periods
Send the census with start-of-care dates and the last three months of claims. We report late NOAs, LUPA periods, returned claims, and a written rate.
Written
Monthly rate
98%
Published NCR
50
US States
BAA
Every Client
Home health billing questions
Straight answers for home health agencies.
What is PDGM in home health?
The Patient-Driven Groupings Model is how Medicare pays home health agencies per 30-day period. Each period is grouped by timing, admission source, clinical group, functional impairment, and comorbidities, which produces the HIPPS code and the payment weight.
When is the home health Notice of Admission due?
Within 5 calendar days of the start of care. If it is late, the period’s payment is reduced by 1/30 for each day from the start of care until the NOA is submitted, including the first five days.
What is a LUPA in home health?
A low-utilization payment adjustment. When a 30-day period has fewer visits than its group’s threshold, between 2 and 6, Medicare pays per visit instead of the full period amount.
Who can perform the home health face-to-face encounter in 2026?
Under the 2026 home health rule, any allowed practitioner can perform it, including a physician, nurse practitioner, clinical nurse specialist, or physician assistant, even if that practitioner is not the one certifying the patient.
How are home health claims billed to Medicare Advantage?
Under each plan’s contract. Most plans require authorization and pay their own rates, so authorization dates and visit counts are tracked per plan rather than under PDGM rules.
How is the fee set?
As a percentage of net collections (flat or per claim in New York) on the book you hand over. No setup fee on the monthly cycle, month to month, with 30 days’ written notice. The written rate follows volume, payer mix, and scope.