Monthly Business Cycle for Provider Direct Billing

/ January 25, 2012

Overview

The processes described in this document describe general protocols for related to electronic billing using Harmony Provider Direct (HPD).

The document has been developed over several months with the participation of ASAP Fiscal Directors & HPD implementation teams, as well as Providers associated with the Massachusetts Council for Home Care Aide Services. In particular, a workgroup composed of staff from ASAPs, Providers, and EOEA met several times to review the processes described below.

Expectations for this document

  • Each ASAP will publish a standard version of this document to their providers. A local version should define local business processes for authorizations, specific contact information, and communications protocols related to electronic billing using Harmony Provider Direct (HPD).
  • A key goal of this effort is to enable providers, especially those who serve multiple ASAPs, to standardize their reconciliation and billing processes.
  • This document to be reviewed again by ASAPs and Providers six (6) months after publishing (i.e. summer 2012).
  • This is a working document. We are publishing a standard version now, but expect it to change over time.

During the Service Month

This section describes items that flow through the HPD Work Queue (or do not flow through the work queue as expected).

  • Verbal Authorizations: the ASAP and the Provider discuss changes to consumer service plans: New consumers, suspension starts, suspension ends, service plan changes, one-time-only services, terminations, etc.
  • Provider logs each verbal change to ensure continuity of service and to ensure accurate billing records.
  • ASAP staff records each new consumer or verbal change in service in SAMS within two (2) business days of the verbal authorization. It is a written authorization once entered to SAMS: it’s visible to the provider in HPD.
  • For each written change to authorization data, the Provider verifies the accuracy of SAMS/HPD data entry that confirms the ASAP’s verbal authorization.
  • Timeliness: if the Verbal Authorization is not entered in a timely fashion then the provider should contact the ASAP for resolution.
  • Discrepancy review (ongoing through the service month): Provider examines current service plan informationand reports, to look for discrepancies between provider's records andHPD/SAMS records. Correction of these discrepancies before month close will reduce billing issues and streamline successful billing.
  • A protocol should be identified by the ASAP includingthe ASAP’s preferred staff to receive, acknowledge and resolve the discrepancy. A standard should be identified for timely correction of such discrepancies.
  • Depending on ASAP, the point-person could be the consumer’s Case Manager, or a dedicated point-person who handles all such requests during the Service Month.
  • EXPECTATION: ASAP establishes a standard turnaround time on acknowledgement and correction of such requests.
  • Discrepancy type 1: If the Verbal authorization and the Written Authorization (SAMS/HPD) do not agree, or if the verbal autho was never entered to SAMS, then the Provider contacts the ASAP to make the correction.
  • Example: suspension date conflicts with date that the worker was in the home.
  • ASAP identifies communication preference (phone, email) to be notified of this type of discrepancy: this might depend on timing, how "old" is the verbal autho, what time of month is it?
  • Discrepancy type 2: SAMS Service Schedule does not match actual permanent service Schedule. Any discrepancy between the consumer's SAMS Service Plan and the permanent pattern of service should be noted by the Provider and communicated to the ASAP to be fixed.
  • Example: if the consumer has a Monday-Wednesday service plan recorded in SAMS, but the consumer has requested that the provider's worker visit every Tuesday-Thursday (no net change to planned units), then this discrepancy should be resolved. The Provider should request that the ASAP update the service plan to match the actual delivery pattern. Alignment of SAMS/HPD plan to actual Provider schedule will reduce billing issues and time required for remediation, and streamline invoicing.
  • Provider performs authorized services in the consumer's home.

After the close of the Service Month

An ASAP point-person (and a backup) for all billing remediation and post-month-close consumer information requests is identified. This person (or team) will work with ASAP case managers to correct SAMS authorization data (service plans, service orders, suspensions, etc.) This contact should understand the Provider’s sense of urgency in resolving discrepancies in a timely manner.

  • The ASAP should identify a communications protocol and a standard expectation for acknowledgement and resolution of billing remediation requests.
  • Recommendation: We strongly recommend that ASAPs identify a single person or team (preferably from the fiscal staff) or group email address to receive billing remediation requests.

Post-Month-Close timeframes

  • NOTE: any of the steps described below may be performed as early as possible in order to speed up the process.Specifically,the remediation process can begin as early as the provider is ready to submit an electronic invoice.

Late Billing

  • The Provider should *NOT*, under any circumstances, record service units for late bills during monthly cycle discussed here.
  • A protocol for late billing should be established by the ASAP in accord with the ASAP contract. This protocol should define deadlines, contact information, standards of service, workflow, and payment practices.
  • It is expected that late billing information will be transmitted separately by the provider to the ASAP, outside of the process discussed here.

1st to the 5th of the month following the Service Month

  • ASAP finalizesmonthly Authos:ASAP staff enters data to SAMS representing all verbal authorizations for the closed service month.
  • OUTPUT: ASAP generates Service Orders after confirmation that all data entry is complete.Target: the 5th business day of the month.
  • Suggestion: the Provider reviews the Work Queue (Service Order pane) or runs a Service Order report to learn that the Service Orders have been generated.
  • Recommendation: Provider staff reviews the SAMS/HPD authorizations (service plans & service orders) for completeness and accuracy relative to all verbal authorizations during the service month before upload.
    Some suggestions to support this review by Providers:
  • Suggestion 1: review the full consumer record, not just the Work Queue, to see all current service plans and suspensions for the consumer.
  • Suggestion 2: reviewthe Consumer Monthly Service Plan Report (CMSP), showing daily details.
  • Suggestion 3:review the Consumer Service Order report, once service orders have been generated by the ASAP for the closed month. Under report settings, select Yes for Show Service Order Details, Show Service Order Instructions, and Show Order Item Comments.
  • A service order may have been increased by the ASAP in certain situations. Therefore the Service Order units for the month may exceed the Service plan's total units for the month).
  • Provider: prepares service delivery records for the units they expect to load to HPD.

6th to the 15th

  • Provider & ASAP work together to resolve discrepancies between verbal and written authorizations.
  • Optional: Provider transmits billing cover sheet for units in the service month, representing all the service units for which they expect to be paid.
  • Some ASAPs may require the transmission of a cover sheet representing all the service units the provider asserts are due.
  • Provider removes billing for units that cannot be billed through HPD. The ASAP and the Provider need to agree on billing protocols for such services.
  • Examples: common area, on-call, shared area, clustered housing
  • Provider enters service deliveries in HPD. Due date for Service Delivery data entry is the 15th of the month. Provider uses HPD functions File Upload, Service Delivery Confirmation Wizard, or one-by-one service deliveries to record service units.
  • During the upload process, the Provider Direct application generates error logsrepresenting units that could not be recorded due to discrepancies in SAMS data.
  • Providerreviews the errors and resolves those it can. If there are errors remaining that need to be resolved with the assistance of the ASAP, the provider is to Export the error log, add a Comment column, and enter comments regarding the cause of the error and expected resolution by the ASAP.
  • Provider then transmits the error log with the comments to the ASAP billing point-person for resolution.

Hard date: 15th of the month for upload of non-discrepancy units by the provider.

16th to the 20th

  • Remediation activity:
  • ASAP & Provider work through unresolved issues on the error logs and remediate: correcting errors in service plans, service schedules, service orders and suspensions, and adjusting SAMS service plans and service orders.
  • ASAP offers guidance and assistance to provider as needed.
  • ASAPinvestigates errors with case managers.
  • ASAP communicates which units may be resubmitted by provider, and which units have been denied.
  • Provider or ASAP: enters service delivery units after remediation.
  • Due date: 20th of the month
  • ASAP & Provider: Second pass remediation if needed.

21st to end-of-month

  • ASAP: finalizes bill and vendor payment.
  • Provider generates a Service Delivery report to preview anticipated payment.
  • Provider transmits the final billing cover sheet to the ASAP. This indicates thatregular billing for the service month is completed and communicates the grand total.
  • ASAP generates anAgency Summary Report in SAMS and compares to the Provider’s total.
  • ASAP: generates Agency Invoices in SAMS. The Agency Invoice restricts the Provider from recording additional service units for the Service Month using HPD. Late bills, if any, will be recorded by the ASAP after the Provider’s bill is finalized, according to the ASAP’s Late Billing Protocol.

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