How home health billing works, start to finish (2026)

The Medicare home health billing sequence step by step: certification, the NOA, 30-day periods and the 432 payment groups, LUPAs, outliers and the final claim.

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Enzo Health Team

Enzo Health

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Read Time: 5 min read

Date: November 5, 2026

The short answer. Medicare pays home health in 30-day periods. Before the first visit you need an order and an eligible patient. Within five days of the start of care you file a Notice of Admission. When a period ends and everything is signed, you send its final claim, and Medicare pays one amount for that period [4][5]. How much depends on which payment group the period lands in [3].

Key takeaways

"HHAs must submit an NOA to their MAC within 5 calendar days from the start of care date" [1]. Late, and the period's payment drops by 1/30th for each day from the start of care until it is filed [1].
The NOA is filed once per admission and "covers contiguous 30-day POCs until you discharge the individual" [1].
A period with fewer visits than its group's threshold is paid per visit instead (a LUPA) [6].

Step 1: Is the patient eligible, and is it certified?

A physician or allowed practitioner certifies the patient for the home health benefit [2]. Medicare's conditions include that the patient is homebound, needs skilled care, is under a physician's or allowed practitioner's care, and has a plan of care [9]. A face-to-face encounter must happen no more than 90 days before the start of care or within 30 days after [2]. Recertification is due at least every 60 days [2].

Check coverage and payer before the first visit.

Step 2: Start of care and the Notice of Admission

You need "a verbal or written order from the physician that contains the services required for the initial visit," and the initial visit done, before you file the NOA [1]. File it with your Medicare contractor within five calendar days of the start of care [1].

Miss the deadline and the period's payment is cut by 1/30th for every day from the start of care until the NOA is filed [1]. After a discharge, a new admission needs a new NOA [1].

Step 3: Which payment group is each 30-day period in?

PDGM sorts every 30-day period into one of 432 groups [3]. Five things decide it:

Admission source. From the community, or after an institutional stay.
Timing. The first period of a stay, or a later one.
Clinical group. One of 12, from the primary diagnosis.
Functional impairment level. Low, medium or high, from the OASIS.
Comorbidity adjustment. None, low or high, from secondary diagnoses.

That is 2 x 2 x 12 x 3 x 3 = 432 [3]. Each group has its own case-mix weight and its own LUPA threshold [7].

A vague primary diagnosis, or an OASIS answer that doesn't match the chart, puts the period in the wrong group, and you are paid for the wrong group.

Enzo QA reviews every chart before submission, flags what needs attention and explains why, and your team makes the call [12].

Step 4: Watch the visit count (LUPA)

Each group's threshold is set at "the 10th percentile value of total visits during a 30-day period," with a minimum of 2 [6]. A period that ends under its threshold "is paid the national per-visit amount" instead of the period payment [6]. For 2026 CMS recalibrated the thresholds "using CY 2024 data" [7].

Visits follow the patient's plan of care, not the claim. What you can do is see the count while the period is still open, so your clinical manager can check that the care the physician ordered is happening. After the period closes, the count is fixed.

Step 5: The final claim

Send the final claim for a period once the NOA has processed, the period has ended (or the patient transferred or was discharged), all services for the period are provided, the plan of care and verbal orders are signed, the face-to-face is done, and the OASIS is submitted and accepted [4]. The claim goes on type of bill 329 [4][1].

Medicare pays a single amount for the period after the final claim is submitted [5]. Every order and the plan of care must be signed first, so check them before the period closes.

Step 6: Outliers and costly periods

When a period costs far more than usual, Medicare pays extra: 80% of the estimated cost above a set threshold [8].

What changed for 2026?

For 2026, CMS estimates home health payments fall about 1.3% overall, roughly $220 million, after two cuts to the base rate (final rule, November 28, 2025) [7][8][11].

CMS also runs the Review Choice Demonstration, extra claim review, in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, and has announced California from January 18, 2027, pending federal approval [10].

Frequently asked questions

Sources

CMS, MLN Matters MM12256, Notice of Admission. cms.gov/files/document/mm12256.pdf (read Nov 2, 2026)
42 CFR 424.22, Requirements for home health services. law.cornell.edu/cfr/text/42/424.22 (read Nov 2, 2026)
CMS, Home Health Patient-Driven Groupings Model. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM (read Nov 2, 2026)
CGS Medicare, Final claim. cgsmedicare.com/hhh/education/materials/final_claim.html (read Nov 2, 2026)
42 CFR 484.205, Basis of payment. law.cornell.edu/cfr/text/42/484.205 (read Nov 2, 2026)
42 CFR 484.230, Methodology used for the calculation of the low-utilization payment adjustment. law.cornell.edu/cfr/text/42/484.230 (read Nov 2, 2026)
CMS, Fact sheet, CY 2026 Home Health Prospective Payment System final rule (CMS-1828-F), Nov 28, 2025. cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-home-health-prospective-payment-system-final-rule-cms-1828-f (read Nov 2, 2026)
CMS, MLN Matters MM14304, Home Health PPS CY 2026 rate update. cms.gov/files/document/mm14304-home-health-prospective-payment-system-cy-2026-rate-update.pdf (read Nov 2, 2026)
42 CFR 409.42, Beneficiary qualifications for coverage of services. law.cornell.edu/cfr/text/42/409.42 (read Nov 2, 2026)
CMS, Review Choice Demonstration for home health services. cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/review-choice-demonstration-for-home-health-services (read Nov 2, 2026)
CMS, Transmittal R13488CP (CR 14304), CY 2026 rate update, Nov 20, 2025, Table 1. cms.gov/files/document/r13488cp.pdf (read Nov 2, 2026)
Enzo, QA. enzo.health/qa (read Nov 4, 2026)
Enzo, EHR. enzo.health/ehr (read Nov 4, 2026)