PPS Payer Type Billing Manual

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Table of Contents

Accounts Receivable

Create NOA for Medicare PPS

In this document, you will find instructions for creating and sending NOA for Medicare, and for other payers/plans that follow Medicare billing guidelines. There have been several changes in the last 3 years in regards to RAP billing, including the name change from RAP to NOA.  The following instructions are for NOA billing, effective January 1, 2022.

NOTE:  This process applies to Medicare, or any other PPS payer that is marked as using NOA 2022 (Codes > Payers > Electronic Claims Setup > NOA 2022 Start Date).

From the Main Menu go to Billing > PPS Billing > RAP Claims.

a. In the first column, click on the Chart Number of any RAP you do not want to include in billing.

b. The chart number will move to the bottom middle column, under Episodes Removed From the Selected List.

c. If you change your mind, you can click the chart number from the bottom middle column, and it will move back to the first column, which is the list of episodes for billing.

**Once the transmission is created, you will use your agency process to upload that transmission to the payer portal.  

Sending NOAs electronically 

If you use a vendor like Ability or eSolutions to transmit your claims you will need to follow their directions on how to upload the claims to their portal.  To find out where on your machine the claims are being saved, go to Billing > HIPAA Transactions > Edit HIPAA Payers.  Select the payer you are interested in and look at the "Transmit Folder" field for the location of where those claims are being saved. 

Sending NOAs by mail

RAP/NOA History:
Click here for RAPs Billed with Service Date Effective 01/01/2021
Click here for RAPs to be Replaced with NOA 2022

Bill End of Episode for PPS Payers

In this document, you will find instructions for billing end of episode (EOE) claims for Medicare PPS, and any plans that follow Medicare billing guidelines. These non-Medicare PPS payers may include payers such as Humana Gold Choice and Tricare.  

For updates related to 2021 RAPs, we recommend running the process from Reports > Billing > 14.03 > 2021 RAPs before completing EOE claims.  This will match up the episodes with Oasis DocID @@ to update the tracking with exported OASIS and returned 485.  

Print 485/VO Not Back: Checking this box will exclude episodes that have errors.  Unchecking will include episodes.  This option will look for orders/485s not returned, starting two weeks before the admit date and on.

Audit Must Be Complete: This will select episodes that have a PPS Episode Chart Audit completed (printed).  Click here for instructions on that process.

Completed Episodes Only: When checked it will select episodes that have a thru date on or before the Select Episodes for Billing Thru date that is selected.  When not checked it will still only select those episodes that have an episode Thru Date on or before the Select Episodes for Billing Thru date, but will also check for errors all episodes that are in a PPS status 4 = RAP no EOE.

RCD UTN Mandatory Starting: For customers who require UTN, this will require episodes to have a UTN before creating a claim. https://www.barnestorm.biz/kbart?id=51469

**Note: If there are any errors, a list of the errors will appear.

Checked will show the number of episodes ready for billing as well as the episodes on the error list.

Not Checked will show the number of episodes that are at least in the PPS Status 4 = RAP no EOE.

In the upper left, click on the Chart Number of any EOE you do not want to include in billing.

The chart number will move to the bottom center of the screen, under Episodes Removed From the Selected List.

If you change your mind, you can click the chart number in the bottom center section, and it will move back to the upper left, which is the list of episodes for billing.

Edit PPS Episodes Screen

Below is an explanation on some of the fields in the Billing > PPS Billing > Edit PPS Episodes screen.

Top, center, two sets of dates: Admit date and Discharge date from the referral.  Below that is the From and Thru dates of the End of Episode claim. 

Select Different OASIS: When the RAP> update runs, the default option is exported OASIS. If an OASIS is locked but not exported, the episode & the OASIS disconnect. Use this button to reconnect them. You may also need to use this option if a SCIC OASIS has been created.

HIPPS: HIPPS code and amount from the time of RAP

RAP/NOA Date: Date RAP created

RAP Serial #: The serial number that was used to create the RAP claim

EOE Date: Date EOE created

EOE Serial #: The serial number that was used to create the EOE claim

EOE Date Paid: Date the EOE was paid

EOE $Paid:  The total amount paid for the episode.  When this does not match the $ Expected, then one of the Reason(s) for not receiving full payment should be checked.

Calculated HIPPS: The calculated HIPPS code amount.

$ Expected:  The amount from the calculated HIPPS code at the end of the episode

LUPA $ Total:  The number of discipline visit times the LUPA amount.  Example, a LUPA SN visit for a selected county is $100 per visit, LUPA PT visit for a selected county is $105.  A patient had 2 SN visits and 1 PT visit in one episode.  The total amount that would show is $305.

Fixed $ Loss:  Each year, CMS publishes guidelines for calculating the outlier payment, for episodes with a large number of visits.  The “fixed dollar loss” is part of that calculation.

$Outlier: This is the additional amount to be added to the HIPPS code payment due to a large number of visits.

Supplies Used $:  The amount of supplies used during that episode

Status: 1 = 485 created but no OASIS; 2 = 485 and OASIS created but no chargeable visit;  3 = 485, OASIS, chargeable visit entered but no RAP created;  4 = RAP Sent but not paid OR RAP sent and paid but EOE not sent yet ; 5 = EOE sent but not paid  ;  6 = Episode is Paid / Denied; 8 = Episode On Hold.

PT, OT, ST, SN, MS, HCA:  The number of chargeable visits made during that episode.

Reason(s) for not receiving full payment:  Some of these are under your control, and some are decided by PGBA during processing.  If an episode is ultimately denied, or due to other circumstances ends up not being paid, then you can check that box to tell the software to drop this episode off the list.  LUPA is automatically checked when the EOE is created and LUPA limit has not been exceeded.  Outlier is checked if the Outlier$ is not $0.  PEP, MSP and Medical Review Downcode can be checked by the agency.  PEP will be used on the 15.16 PPS Cost Reports. Episode Has No Chargeable Visits button will be enabled if there is a RAP created, but the Thru date is 10+ days ago and there are no visits for the episode. 

Troubleshooting features

Fix Amount Billed in A/R: Use this feature if someone removed the amount billed in the AR by mistake. It will add the amount billed back into the AR. You will also want to run the Update PPS tracking to add adjustments, as well.

14.03 PPS Tracking Report

Go to Reports > Billing14.03 PPS Tracking Report.  This report tracks the episode status from beginning to end.  There are various filtering options.  See details below on how to run the report.

Note:   There is also a tab option to search for Missing Episodes.   A missing episode can occur when a 485 is printed from POC. The search for missing episodes looks for visits charged to a PPS payer that do not have an episode in PPS tracking. The billing staff member needs to come to this screen at least once a week, before creating billing, and run this report. This screen also has a button that will create all the missing episodes for you.  Please see additional article in the Related Links below, for additional information.

How to Run the Report
  • From Dates = Selects episodes based on the from dates.
  • Thru Dates = Selects episodes based on the thru dates.
  • SOC Episodes 1st 30 days
  • SOC Episodes 2nd 30 days: the other half of the same 485 where the pt was not d/c during the first 30-day episode

  • 485 no OASIS = Shows episodes that have a 485, but no OASIS yet.
  • OASIS no Visit = Shows episodes that have a 485, OASIS but does not have a first chargeable visit yet.
  • Visit no RAP = Shows episodes that meet all criteria but the RAP has not been created yet.
  • RAP no EoE = Shows 1)episodes that have the RAP created but not paid yet or 2) RAP paid but no EoE yet.
  • EoE sent, not paid = Shows episodes that have an EOE created but has not been paid yet.  An additional option will appear to select the Claims created Thru date (default will be 14 days). 
  • EoE paid = The EOE has been paid
  • On Hold - RAP - Shows RAPS/NOAs that have been put on hold.
  • On Hold - EOE - Shows EOEs that have been put on hold.
  • All of the above - Shows all episodes with status' above.

  • Program(s) / Payer(s) /Team(s) Filter report by entering program, payer, team number(s). Or leave blank to select all.
  • Medicare Only = Selects Medicare PPS episodes (Payer has PPS = Yes and Pay Class = B).
  • Non-Medicare Only = Selects non-Medicare PPS episodes (Payer has PPS = Yes and Pay Class not = B).
  • Both = Selects both Medicare and non-Medicare episodes.

 Print By Options:

  • Patient’s Name = Orders the report by the patient’s last name.
  • Episode Status,Patient’s Name= Orders the report by the status above (485 no OASIS, etc) then by the patient’s last name.
  • Episode Status,From Date= Orders the report by the status then by the episode from date.
  • Payer, Patient’s Name= Orders the report by the program/payer number and then by the patient’s last name.
  • Episodes ON HOLD –Except Orders= Will only show episodes that are on hold due to automatic billing errors.  This does exclude episodes with just orders outstanding.
  • Episodes ON HOLD –ALL= Will only show episodes that are on hold due to errors and DOES include outstanding orders.
  • NOTE:  If you want to only view episodes manually put on hold, check the appropriate On-Hold option on the left, and choose one of the top 4 Print By options.
  • Episodes with KX - Late Reason = Will only show episodes that have been marked with KX and comments for the late reason for RAP/NOA submission.
  • Double-space the Tracking Report = Leaves a blank line between each episode.
  • Print the Summary Only = Only prints the last part of the report that shows stats only.
  • PPS Primary Payer Only = This will only select episodes that have a primary PPS payer entered in the Referral > Payer screen.
  • Episodes With Errors/Issues Only = Only includes episodes with issues.  This will pull up a spreadsheet that shows all errors tied to the episode. 

      How to Read the Report

  • HIC# =Medicare/Insurance # from the Referral > Payers screen.
  • TM = Team number.
  • Payer = Shows the program number and payer number.
  • Status = List the status that the episode is currently in.
  • FromDate/ThruDate = Episode dates.
  • M0090 Dt = M0090 date on the OASIS for the episode.
  • RFA = Reason for Assessment on the OASIS for the episode.
  • HIPPS = HIPPS code that was generated on the RAP claim.
  • $Amount = The amount associated with the HIPPS code.
  • Vx = The number of chargeable visits for that episode.
  • RAP Date / Days = Date the RAP was created and the number of days between the From episode date and the date RAP created.
  • EOE Date / Days = Date the EOE was created and the number of days between the Thru episode date and the EOE created.

     Summary on last page:

  • SOC Episodes / 2nd 30-day SOC Episodes = The number and HIPPS amount related to the Start of Care episodes.
  • Recert Episodes / 2nd 30-day Recert Episodes = The number and HIPPS amount related to the Recert episodes.
  • New Episodes = The number of episodes that do not have an OASIS with a HIPPS code yet.
  • Billed after = Shows the number of episodes that were billed after the from and thru date of the report.
If certain patients do not appear on the report:
When a 485 is printed from POC, it does not generate an episode in tracking, since POC and billing are not connected.  On the 485 screen, when you click on the 485 dates, there's a button at the middle top to Create PPS, which can be used to get the episode into tracking.  Also, as part of 14.03, is a tab for Search for Missing Episodes, which looks for visits charged to a PPS payer where there is no corresponding episode.

***Payers that are not PPS do not generate episodes.***

NOTE:  The format may display differently based on the options you've selected.

Print Monthly ProRated
When a 30-day episode covers parts of 2 consecutive months, this report will allocate the episode amount into each month. The allocation can be based on either the number of days in each month, or the number of visits in each month. For example, an episode from
Apr 21 - May 20 would have 10 days in Apr and 20 days in May, so allocating based on days would put 1/3 in Apr (10 days of the 30 total) and 2/3 in May. But the episode may have 10 visits between Apr 21 - 30, and then 5 visits May 1 - May 20; allocation based on 
visits would be 2/3 in Apr (10 visits of the 15 total) and 1/3 in May. Another option is to use the EOE Dollars. For episodes that have not had the EOE created, the value is one penny. Choosing this option will rate each of those episodes at the HIPPS amount before allocating.

Troubleshooting Tips

485 Missing = There's not a matching 485 episode for the billing cert period 

485 Not Mailed = 485 has been created but not yet mailed to the physician 

485 no OASIS = There has been a 485 identified but the OASIS is not entered or is not completed yet.Check the OASIS screen to see if the patient has the SOC or Recert OASIS entered and locked. 

Select A Different OASIS button:  

If the OASIS has been created, but still shows as "485 No OASIS" on the report, try manually selecting the correct OASIS.  Go to Billing>PPS Billing>Edit PPS Episodes.  Pull up the patient and select the episode.  Click Select A Different OASIS button.  Select the correct OASIS.  Exit and try to bill the RAP/NOA.

OASIS Not Xported = The OASIS has not been exported. 

OASIS no Visit = There is not a first chargeable visit in the Locked+Chg status.

Dr Not in PECOS = The physician assigned to the 485 is not enrolled in PECOS.  Go to Codes Other Basic Codes and pull up that physician.  Click on Validate using NPPES and then Import information to see if that updates the PECOS. You can also try the following link to verify, here

Visit no RAP = This means the 485, OASIS and first chargeable visit has been entered appropriately but the RAP has not been created yet.

RAP no EOE = This can be a couple of different things.

   o The RAP has been created and sent but not paid yet.  If the RAP claim is aging but has not been paid yet then you will want to check with the payer to see if there were any issues with the claim. 

   o The RAP was sent and paid but the EOE has not been generated yet.  If the EOE has not been generated yet then the episode will either show up on the EOE billing screen to be sent or it will show up on the EOE error report. The patient must have all documentation returned, the Thru date in the past, and all visits marked as Locked+Chg.

EOE sent, not paid = The EOE has been generated and hopefully sent to the payer.  If the claim is aging then check with the payer to see if it is processing or if there were any errors.   See the article attached to view the 999 and 277CA files to see if there were any issues with the claim. 

EOE paid = This is when the episode has a zero balance and everything for the episode is finished.

On Hold RAP or EOE = Something is holding the RAP or EOE from being generated.  Usually from outstanding Orders, 485s, Face to Face; and also if you've manually marked the episode as On Hold.  The report will indicate the reason(s) why the claim is being held.

Post Electronic Remittance Advice

You will use Accounts Receivable > Post Payments >Post Electronic Payments to post any ERA files. 

You will first need to download the ERA files to the appropriate folder.

Post Elec Remit Files (835/ERN):

The checkbox next to this button only gets used when a change has been made in the software to handle something new and you would need to re-post the RA.

Post NonMedicare PPS Payments

This is a very detailed article that walks through the steps on how to post Medicare Advantage payments.  The payments must be entered a certain way in order for the PPS tracking system to update the episode status to PAID.  These instructions do not apply to traditional Medicare.  First, you will need to verify the correct ERA Codes (payment/adj codes) are set up correctly.

Set up the ERA Codes

In order for the Update PPSTracking From Payments to work properly you must set up the ERA codes first.  This is a place where you set up the payment and adjustment codes for Medicare and non Medicare PPS payers.  You have two choices, you can use the same EOE payment, and Adjustment codes for all PPS payers (Medicare and non Medicare) or you can use one set of codes for Medicare and another set up codes for non Medicare.   Updating the PPS Tracking will not work if you use a different set of codes for each nonMedicare payer.  Example: having two codes set up for each payer (EOE, Adjustment).

If you do not have any nonMedicare PPS payment/adjustments codes set up yet and wish to do so, see article number 50477 on how to set them up.   

To set up which payment and adjustment codes to use go to Accounts Receivable > Post Payments >Set Up ERA Codes.  The picture below is just the example of what the nonMedicare codes look like. 

**NOTE:  Medicare discontinued RAP payments effective date of service 01/01/2021.

Set up the payment codes in the payer screen

You can set up the payment code in the payer screen so that when you’re ready to post the payments, the RAP and EOE code is already there.  From Codes > Program Related Codes > Payer, enter the program and payer number.  

Enter the RAP payment code in the pay code section.  Enter the adjustment code in the Adj code section.   There’s no need to enter the adjustment code when posting EOE payment.  The Update PPS Tracking part will do that for you. These codes will be the same codes that you have set up in the ERA Codes from above.   

Process of posting payments

This is what the AR Inquiry screen will look like when you first create the RAP.   It will be timestamped with that day's date and the Amount Billed of 0.01 to acknowledge the episode as created in Barnestorm.   The Year/Mo is the billing month.  Each 485 episode can have up to 2 billing periods; the first 30 days is marked with an A and the second 30 days is marked with an B. This is especially helpful when both 30 day periods start in the same month. 

Entering the EOE payment:  Accounts Receivable > Post Payments > Post Paper Remittances

The next steps would be to create and send the EOE claim when ready. After the EOE payment has been received, you can enter it into the Post Paper Remittances screen.  Below is an example of how it should be entered.   

The next step is to post any payer adjustments and mark the episode as Paid/complete.  Click Post Payments tab and select Update PPS Tracking From Payments. (You will need to do this step for manual postings and for electronic postings for PPS payers)

Post Medicare Advantage Co Pay / Co Insurance Payment

This article will go through the steps on how to post RAP and EOE payments for Medicare Advantage Plans and then post the correct adjustment amount and transfer the patient responsibility over as a self-pay. You may need to create new Payment/Adjustment codes - see article link Setup a Payment / Adjustment Code

Overall, what you’ll be doing is creating the RAP and EOE payment and updating the PPS Tracking. You’ll need to modify the adjustment code and amount so that the correct amount is transferred over to the patient as self-pay (the amount they are responsible for paying out of pocket). You’ll be able to print a statement that shows the Medicare Advantage Plan’s payment history, including what is being transferred over the patient. 

After the insurance has paid the RAP and EOE, you can enter the accounts receivable to reflect. The instructions below are for a patient that has already had a RAP payment entered, and we are entering an entry for the RAP take back and the EOE payment.