Final Claim
The final claim is the Medicare claim a home health agency submits after each 30-day payment period ends, reporting every visit, supply, and diagnosis for the period along with the HIPPS code that identifies its case-mix group. It is how the agency actually gets paid under the Patient-Driven Groupings Model (PDGM), since the Notice of Admission that precedes it carries no payment.
What goes on the claim
The final claim is an institutional claim, type of bill 329, built from several layers of data. The revenue code 0023 line carries the HIPPS code for the period. Each visit appears as its own line with the discipline's revenue code, the HCPCS G-code describing the service, the visit date, and units in 15-minute increments. Non-routine supplies, diagnoses (principal plus up to 24 secondary), period dates, and occurrence codes for events like recent inpatient discharges round it out. Because so many upstream artifacts feed it, the final claim is where every documentation gap in the episode eventually surfaces.
How Medicare adjudicates it
The claims system validates the final claim against the admission's Notice of Admission and processes it in sequence behind any earlier period claims. It checks the beneficiary's claims history and recodes the timing and admission source positions of the HIPPS code when Medicare's records disagree with the submission. It counts the visit lines against the case-mix group's LUPA threshold and converts the period to per-visit payment if the count falls short. The paid amount on the remittance therefore reflects Medicare's determination of the group, not necessarily the agency's, which is why submitted-versus-paid reconciliation belongs in every revenue cycle routine.
When to bill and what blocks it
The claim can be submitted once the 30-day period ends and all services are documented, and it must land within Medicare's 12-month timely filing window. In practice, the common blockers are internal: unsigned physician orders, a plan of care awaiting signature, OASIS not yet completed or submitted, visits missing documentation, and sequential billing edits from a stuck earlier claim or unprocessed NOA. Every day a period sits unbilled extends days sales outstanding, so the operational goal is a short, measured lag between period end and claim submission.
What good pre-bill QA looks like
Clean final claims come from a pre-bill checklist run before submission, not from reworking rejections afterward:
- All orders and the plan of care signed and dated by the certifying practitioner
- Face-to-face encounter documentation on file and compliant
- OASIS completed, locked, and submitted for the relevant assessment
- Every scheduled visit either documented or resolved as missed
- Diagnoses on the claim consistent with the coded record
- NOA accepted and prior period claims processed
Agencies that track clean claim rate and first-pass payment rate by blocker category find their revenue cycle problems are usually three or four recurring defects, not hundreds.
Frequently asked questions
When can the final claim be submitted?
After the 30-day period ends, once all services are documented and the supporting requirements, signed orders, OASIS, and an accepted NOA, are in place. It must be filed within Medicare's 12-month timely filing limit, but well-run agencies bill within days of period end.
Why did Medicare pay a different amount than the claim calculated?
Most often because Medicare recoded the timing or admission source from its own claims history, changing the case-mix group, or because the visit count fell below the LUPA threshold and the period paid per visit. Comparing the paid HIPPS code to the submitted one on the remittance identifies the cause.
Is there a final claim for every 30-day period?
Yes, each payment period is billed on its own final claim, so a 60-day certification produces two claims. The Notice of Admission is filed only once per admission, but it pays nothing; the final claims carry the payment.