PPS Payer Type Billing Manual

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.

• In the Middle Column:  Select a From and Thru date.  The episodes "From date" will automatically be set to the oldest From Date that has not been billed, that still qualifies as billable under Medicare guidelines.
• You can type in a specific "team," or "program" number, or leave blank to include ALL.
• Click the Update Episodes button in the middle column. The software will begin to match up OASIS and visits to unbilled episodes.  This may take a few minutes based on episode count, and your internet speed.
• If there are any errors found, a RAP Error report will generate. 
• You may correct the errors and then return to billing. Click the Close button to close the errors. If you make any changes, you will need to repeat the Update Episodes step.  If not, continue to next step.

• In the Middle Column, select the payer you want to bill for.  
• In the First Column, the patient listing of ready NOAs will appear for that payer.  
• To remove NOAs that you do not want to send:

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.

• Make sure that the list in the first column includes only the NOA episodes you wish to bill.
• Click the Create RAP/NOA Claims button in the Third Column. Wait while the software creates the NOA claims.
• You may receive a warning message that a doctor may have a missing or invalid NPI.  If so, take note of the patient and make the correction.  You will need to exit the RAP/NOA screen, correct the problem then restart the NOA process. 
• When the NOA transmission is complete, a new file has been created, and the name is shown at the top of the screen.
• Click the icon with the printer in the upper left corner to print the list of episodes.
• Click the X in the upper right corner to close the printer page.

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

Sending NOAs by mail

• Click Print UB04/1500 at the top of the screen. (Main menu:  Billing tab > Print UB04/1500)
• Select the payer you just created the NOA for.
• Click the RAP button. The RAP claims will show up on the left side of the screen under the list of payers. 
• Click the serial number of the RAP claim you want to print.
• At this point if you should insert UB04 paper into the printer, if needed. 
• Click the Print All Claims in This Batch button. 
• Click the icon with the printer in the upper left corner to print the claims.
• Click the X in the upper right corner to close the printer page.
  

• Mail or fax the claims according to the payer.

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.  

• Click the Billing button from the Main Menu > PPS Billing > End of Episode Claims.
• Select from the options at the top, middle as needed

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

• Select the payer you want to bill from the list in the middle of the screen. You will see a status bar working through the process of updating the PPS Tracking.

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

• (Optional) Print the list of errors and fix any that can be fixed. 
• Click the Close button to hide the errors.
• The number that shows up next to the payer name will depend if you have Completed Episodes Only checked or not.

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.

• The EOE episodes ready to bill for the selected payer will appear to the left.
• To remove EOEs that you do not want to bill:

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.

• Make sure that the list on the left shows the EOE episodes you wish to bill.
• Click the Create Billing button on the right. Wait while the software creates the EOE claims.
• When the EOE batch is complete, a new file has been created.
• Click the Print Details button to print the list of episodes.  A new screen will come up with a print preview.  The serial number (transmission) will appear in the header.  Click on the printer icon to print then click on Close.
• Click the Hide button to go back to the billing screen. Note that the right side of the screen indicates that the created EOE claims is complete.
• If the claims need to be printed:  Click the Print UB04/1500 button.
• The claim file you just created will automatically be selected.
• Click the Print All Claims or selected claim.
• Click the icon with the printer in the upper left corner to print the claims.
• Click the X in the upper right corner to close the printer page.

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.

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):

• If your agency has multiple payer types you can use the bullet shown at the top of this screen to select which ERA types you need to look for; HH Medicare and PPS, Hospice Medicare and All other payers.
• If you have multiple folders setup for different payers you will select the folder where your ERA  is saved. A list of 835 or ERNs will appear in the middle of the screen.  Select the ERA file you need to post. 
• Click the Process this 835/ERN File button from the right side of the screen.  This button will save ICNs for rebilling and create service line posting details. 

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.

• Next, you have the Print Summary and Print Detail buttons that will appear.  Print these reports, as needed.
• Depending on the payer type you are processing, you may see a Print Denials button.  Checking Include All Unpaid Services will print everything, including where you bill more than the pay.       
• Checking Skip 45 will skip the contract adjustment to help shorten the printed list.  Click and print, as needed. 

• Click the Create ERA Entries button to generate payment entries.  A Set A/R Posting Date pop up box will appear.  It will default the bank date, only change it as needed, click on OK.  Print the report as needed and then click the Close button.
• Click the Post to A/R button.  A pop up box will appear once it is finished.  Click on OK.  
• PPS Payers Only - if you are posting PPS payments you will then need to click the Create PPS Adjustments button.  These steps will post any adjustments, as well as mark the episode as Paid/Complete.  This window will open:

• Once posting is complete and you want to remove the ERN file from the screen.  Click the Archive This 835/ERN File button to remove the ERA file from the list.  Check Move All ERN Files to the 835 folder if that is what you want to do. 

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.   

• Type in the patient name or chart number, and select the correct 30 day period (A or B) you are posting against
• The Add/Edit Accounts Receivable window will open
• Change the Transaction Date to the bank date, or the date the payment was received
• For the $Amount #1, key in the EOE payment, making sure to use the correct EOE posting code
• For the $Amount #2, key in the EOE adjustment amount.    (This is Optional, if you leave it blank the system will automatically post the adjustment during the steps below.)
• Enter any comments and Click on Save.
• Follow tab options to View Details, and View Totals
• If totals look correct, click Approve Totals
• Click Post Entries to complete the posting 

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)

• Check the box above Step 1. This step will make sure nonMedicare AR is posted correctly.
• Click the Step 1 - Update PPS Tracking button.  (If no new payment is found, the process stops here.  If payment(s) is found, the Step 2 button will activate.)  Click Close to exit the preview.
• Click the Step 2 - Create A/R Adjustments button (If nothing is found, the process stops here.  Either the payer paid in full, or you manually entered the adjustment in the steps above) Click Close to exit the preview.
• Click Step 3- Post to A/R button to complete the posting/mark episode as PAID/Complete.  Click X to exit the window.