🔒
LUCA LLC Proprietary Intellectual Property
This billing system, all workflows, SOPs, and methodologies are proprietary to LUCA LLC's RCM Division.
Skyline Home Health Care is a client engagement. Not for external distribution without written authorization
from Samuel Mfinanga, Managing Director, LUCA LLC.
📋 Client Profile
| Client | Skyline Home Health Care |
| NPI | 1104334887 |
| Address | 10800 E Bethany Dr, Suite 550 E&F, Aurora CO 80014 |
| Phone | 720-741-8551 |
| License | Colorado Class A Home Health Agency |
| Medicare MAC | CGS Administrators — J15 (Colorado) |
| EMR | Synergy EMR |
| EVV | Sandata Mobile Connect |
| Clearinghouse | Waystar |
⚠️ Critical Deadlines
| SOC + 72 hrs |
LUCA internal NOA SLA |
| SOC + 5 days |
CMS NOA deadline ($50/day penalty if late) |
| SOC + 5 days |
OASIS submission to iQIES |
| Day 55 |
Recertification OASIS window opens |
| Day 60 |
Final claim submission via Waystar |
| Monthly · 5th |
ARIA billing operations report due |
| Weekly · Friday |
Claim batch submission |
| ADR · 14 days |
LUCA internal ADR response SLA |
| Denial · 120 days |
Level 1 appeal filing deadline |
🏢 LUCA Agent Responsibility Matrix
| Function | LUCA Primary | LUCA Secondary |
|---|
| Referral intake & admission | HAVEN | APEX |
| Eligibility verification | HAVEN | CRED |
| Authorization management | CRED | HAVEN |
| NOA submission & monitoring | ARIA | HAVEN |
| EVV compliance | HAVEN | Clinical |
| OASIS + iQIES submission | CODA | HAVEN |
| PDGM coding & grouper | CODA | ARIA |
| LUPA risk monitoring | HAVEN | APEX |
| Final claim submission | ARIA | — |
| Payment posting & ERA | ARIA | VERA |
| Denial management | VERA | ARIA |
| Medicare appeals | VERA | ARIA |
| A/R follow-up & collections | VERA | — |
| Monthly billing report | ARIA | — |
| Compliance oversight | SHIELD | ARIA |
⚙️ LUCA 9-Stage RCM Pipeline — Skyline Engagement
LUCA's proprietary home health RCM methodology. Each stage has a defined LUCA agent owner, SLA, and gate criteria before advancing.
Stage 1
Referral & Intake
HAVEN · APEX
SLA: 24 hours
Output: Complete admission packet
Stage 2
Eligibility & Auth
CRED · HAVEN
SLA: 24 hours
Output: Auth number on file
Stage 3
NOA Submission
ARIA · HAVEN
LUCA SLA: 72 hours
Output: NOA accepted by CGS
Stage 4
Service Delivery + EVV
Clinical · HAVEN
SLA: Real-time
Output: EVV-verified visits
Stage 5
OASIS + PDGM Coding
CODA · HAVEN
SLA: Per episode
Output: Coded OASIS → iQIES
Stage 6
Final Claim Submit
ARIA
SLA: Day 60
Output: Clean claim via Waystar
Stage 7
Payment Posting
ARIA · VERA
SLA: 3 days post-ERA
Output: ERA matched + posted
Stage 8
Denial Management
VERA · ARIA
SLA: 30-day window
Output: Denial resolved/appealed
Stage 9
A/R Collections
VERA
SLA: 30/60/90 day
Output: Balance fully resolved
🚪 Stage Gate Rules — Advancement Criteria
| Gate | From → To | Criteria to Advance | Blocked If |
|---|
| Gate 1→2 | Intake → Eligibility | Patient in Synergy EMR; referral source documented | Missing referral documentation |
| Gate 2→3 | Eligibility → NOA | Medicare Part A eligibility confirmed; auth on file (non-Medicare) | No active benefit period; no auth |
| Gate 3→4 | NOA → Services | NOA accepted by CGS in DDE; EVV setup in Sandata | NOA pending or rejected |
| Gate 4→5 | Services → Coding | All visits EVV-verified; physician orders signed; OASIS complete | Missing EVV records; unsigned orders |
| Gate 5→6 | Coding → Claim | PDGM group confirmed; LUPA threshold met; OASIS accepted iQIES | LUPA risk; OASIS pending |
| Gate 6→7 | Claim → Payment | Clean claim submitted; 277CA accepted by Waystar | Claim rejected by clearinghouse |
| Gate 7→8 | Payment → Denial | ERA received; full/partial payment posted | Denial code on ERA → routes to Stage 8 |
| Gate 8→9 | Denial → A/R | Appeal filed; awaiting decision | Missing medical records for appeal |
| Gate 9→Close | A/R → Resolved | Balance zero: paid, written off, or patient-billed | Open balance >120 days without action |
💳 Payer Portfolio — Skyline Home Health Care
| Payer | Type | Auth Required | Claim Format | Avg Pay Cycle | LUCA Lead |
|---|
| Medicare Part A | Federal | NOA only (no prior auth) | UB-04 | 14–21 days | ARIA |
| Colorado Medicaid | State | PA required before first visit | UB-04 | 21–30 days | ARIA |
| RMHS | Managed Medicaid | Auth + EVV mandatory | CMS-1500 | 21–35 days | ARIA |
| Humana | Medicare Advantage | Auth required | UB-04 | 14–21 days | CRED |
| Aetna | Commercial | Auth required | CMS-1500/UB-04 | 30–45 days | CRED |
| Pinnacle | Commercial | Auth required | CMS-1500 | 30–45 days | CRED |
| UnitedHealthcare | Medicare Advantage | Auth required | UB-04 | 14–21 days | CRED |
⚠️
Auth Expiration Warning Protocol (HAVEN)
HAVEN monitors all non-Medicare authorizations via Monday.com Section 200. Alerts are triggered 14 days before expiration.
CRED must initiate renewal request immediately on alert. Clinical scheduler must not schedule visits beyond auth end date.
⏱️ Authorization Lead Times
| Payer | PA Lead Time | Auth Duration |
|---|
| Medicare Part A | N/A (NOA only) | 60-day episodes |
| Colorado Medicaid | 3–5 business days | Per auth period |
| RMHS | 5–7 business days | Per service period |
| Humana | 3–5 business days | Per episode |
| Aetna | 3–5 business days | 60 days typical |
| Pinnacle | 3–5 business days | Per auth |
📡 System Connections
| System | Purpose | Used By |
|---|
| Synergy EMR | Patient records, claim generation | HAVEN, ARIA, CODA |
| Waystar | Clearinghouse — claim submission | ARIA |
| CGS DDE | MAC portal — NOA & claim status | ARIA, HAVEN |
| iQIES (CMS) | OASIS submission & quality reporting | CODA |
| Sandata Mobile Connect | EVV — Colorado Medicaid mandate | Clinical + HAVEN |
| Availity | Eligibility verification | HAVEN, CRED |
| Monday.com (18406852067) | Patient board tracking | HAVEN, APEX |
💰 LUCA PDGM Framework — 5 Payment Factors
LUCA's proprietary 5-factor PDGM coding methodology captures maximum reimbursement for every 30-day episode. CODA owns all PDGM coding for Skyline.
| # | Factor | Options | Revenue Impact |
|---|
| 1 | Timing | Early (1st 30-day period) vs. Late (2nd+) | Early pays 15–20% more |
| 2 | Admission Source | Community vs. Institutional (inpatient within 14 days) | Community = higher base rate |
| 3 | Clinical Grouping | 12 groups (see below) | Determines base payment category |
| 4 | Functional Level | Low / Medium / High (OASIS GG items) | Low impairment = higher payment |
| 5 | Comorbidity Adjustment | None / Low / High (secondary ICD-10 interactions) | Up to +20% for High comorbidity |
🏥 12 PDGM Clinical Groups
MMTA-Cardiac
CHF, hypertension, CAD, arrhythmia
MMTA-Endocrine
Diabetes mellitus, thyroid disorders
MMTA-GI/GU
Ostomy, UTI, GI disorders
MMTA-Infectious
Wound infections, cellulitis, septicemia aftercare
MMTA-Other
Anemia, COPD, cancer, malnutrition
MMTA-Respiratory
COPD, asthma, pneumonia
MS Rehab
Fractures, joint replacements, musculoskeletal
Neuro Rehab
Stroke, MS, Parkinson's, TBI
Wound
Surgical wounds, pressure ulcers, diabetic foot
Behavioral Health
Depression, anxiety, psychiatric disorders
Complex Nursing
IV infusion, TPN, tracheostomy, ventilator
Medication Management
High-risk medication monitoring, reconciliation
🚨 LUPA Monitoring Protocol
🚨
LUPA Risk = 40–80% Revenue Reduction
When visits fall below the minimum threshold for a clinical group, full PDGM payment is replaced
with per-visit payment rates. HAVEN monitors daily and alerts APEX + clinical supervisor when
any patient is at 1 visit below threshold with 7+ days remaining in the period.
Most SN/PT Groups
2
Minimum visits per 30-day period
High-Therapy Groups
3–4
Minimum visits per 30-day period
LUCA Alert Trigger
−1
Alert at threshold minus 1 visit
Revenue at LUPA Risk
−60%
Avg revenue loss if LUPA triggered
🚫 Denial Code Response Table
| Code | Description | LUCA Response | Owner |
|---|
| N688 | NOA not on file | Submit NOA immediately; appeal if past window with cause documentation | ARIA |
| N657 | F2F documentation deficient | Request amended F2F from physician; Level 1 appeal with complete records | VERA |
| CO-167 | Not medically necessary | Clinical review; VERA authors appeal with nursing notes + OASIS evidence | VERA SHIELD |
| CO-97 | Bundled in global payment | Verify episode dates; submit corrected claim | ARIA |
| CO-16 | Missing/incomplete documentation | Identify missing item; resubmit complete claim | ARIA |
| AUTH | Authorization missing/expired | CRED requests retroactive auth; formal appeal if denied | CRED |
| PR-1 | Deductible | Bill patient per Medicare Part A deductible schedule | VERA |
| PR-96 | Non-covered charge | Write-off or patient bill per LUCA write-off policy | ARIA |
⚖️ LUCA Medicare Appeals Ladder
| Level | Name | Filed With | Deadline | Decision SLA | Approval Rate |
|---|
| L1 |
Redetermination |
CGS Administrators (J15) |
120 days from denial |
60 days |
45–55% |
| L2 |
Reconsideration |
MAXIMUS Federal (QIC) |
180 days from L1 denial |
60 days |
Favorable for clinical |
| L3 |
ALJ Hearing |
OMHA |
60 days from L2; min $180 |
90 days |
50–65% |
| L4 |
Appeals Council |
DAB |
60 days from L3 |
90 days |
Legal/factual errors only |
| L5 |
Federal Court |
U.S. District Court |
60 days from L4; min $1,960 |
Case-dependent |
Samuel approval required |
📄
ADR Response — LUCA Internal SLA: 14 Days
When CGS issues an Additional Documentation Request, the 30-day CMS clock starts from the ADR letter date.
LUCA's internal SLA is 14 days. ARIA + HAVEN compile the complete medical record package (cover sheet, POC,
OASIS-E, F2F, all visit notes). Submit via CGS portal. Never exceed 28 days. Any missed ADR = immediate
Samuel Mfinanga escalation.
Clean Claim Rate
≥95%
Alert: <90% → process audit
First-Pass Payment
≥90%
Alert: <85% → CODA review
Collection Rate
≥94%
Alert: <90% → ARIA escalation
Denial Rate
≤5%
Alert: >8% → SHIELD review
Appeals Win (L1)
≥50%
Alert: <40% → doc review
NOA On-Time Rate
100%
Any late NOA = immediate flag
A/R 0–30 Days
≥75%
Target % of total A/R
A/R 90+ Days
≤3%
Alert: >5% → VERA escalation
📊 A/R Aging Targets
| Age Bucket | Target % of Total A/R | Alert Threshold | LUCA Action |
|---|
| 0–30 days | ≥75% | <70% | Weekly review until resolved |
| 31–60 days | ≤15% | >20% | VERA outbound payer contact |
| 61–90 days | ≤7% | >10% | VERA + ARIA management review |
| 91–120 days | ≤3% combined | >5% combined | ARIA + Samuel decision on appeal/write-off |
| 120+ days | ≤3% combined | >5% combined | VERA collection attempt; evaluate write-off |
📋 Monthly Billing Operations Report Checklist (ARIA)
□
All $ figures from Synergy EMR — no estimates□
A/R aging pulled on last business day of month□
No PHI in report — episode IDs only□
LUPA risk section completed by APEX□
Auth expiration section completed by HAVEN□
Denial codes verified against actual Waystar ERA□
All open items have named agent owner + hard due date□
Filed to LUCA: 01 - LUCA LLC/04 - RCM/.../Skyline/Monthly Reports/□
Filed to Skyline: 03 - Skyline/04 - Billing/05 - Monthly Reports/□
Delivered to Samuel + Lucy by 5th business day