What is a LUPA? An acronym for Low Utilization Payment Adjustment, a claim is considered a LUPA when four or fewer visits are provided during a 60-day episode. Medicare reimburses your agency for this limited number of visits at an established per-visit rate, instead of the full episode rate.

If your patient's visit schedule is likely to result in a LUPA, and you know it from the patient admission, should you...

1. bill the Request for Anticipated Payment (RAP) as normal and let Medicare recoup the payment on the claim (EOE), or
2. bill the claim (EOE) as a "No-RAP" LUPA, i.e., file a claim without submitting a RAP?

A: To protect your agency's status as the primary home health agency serving this patient, and to prevent another agency from submitting a RAP behind you on this episode, we recommend filing a RAP. This action will establish the episode and designate your agency as the primary home health agency for the patient in the Common Working File (CWF).

For more information on filing "No-RAP" LUPAs, we have included the CMS Medicare Claims Processing Manual overview below.

40.3 - HH PPS Claims When No RAP is Submitted - "No-RAP" LUPAs
(Rev. 1, 10-01-03)
HH-475.3, A3-3638.25
A RAP and a claim must be submitted for all episodes for which Medicare makes payment based on HIPPS codes. However, if the HHA is aware prior to billing Medicare that it will supply four or fewer visits in the episode, it may submit only a claim. In these cases, the claim is called a "No-RAP LUPA," since the HHA is aware the claim will be paid a LUPA payment adjustment based on national standard visit rates. HHAs may submit both a RAP and a claim in these instances if they choose, but only the claim is required. HHAs should be aware that submission of a RAP in these instances will result in a recoupment of funds for the episode since the payment for a RAP will exceed payment for four or fewer visits. HHAs should also be aware that the receipt of the RAP or a "no-RAP LUPA" claim causes the creation of an episode record in CWF and establishes an agency as the primary HHA which can bill for the episode. If submission of a "No-RAP LUPA" delays submission of the claim significantly, the agency is at risk of not being established as the primary HHA for that period.If the agency chooses to submit this "No-RAP LUPA" claim, the claim form should be coded like other claims as described in §40.2.

Reference: CMS Publication 100-04 Medicare Claims Processing Manual; Chapter 10; Home Health Agency Billing

Pamela Pruitt has over 20 years experience as an accountant, with a majority in public accounting specializing in health care industry such as physicians, anesthesiologists, dentists, hospitals/clinics, etc. Ms. Pruitt is the Chief Accountant at All Nursing Home Health Services, Inc. in Houston, TX, as well as a Certified QuickBooks Pro Advisor, Certified Public Bookkeeper and Certified Bookkeeper. After hours, she blogs on Jobing.com and runs a business providing services to small businesses such as bookkeeping, accounting, and software setup, among other services.