9-Stage Revenue Cycle · Medicare PDGM · Colorado Medicaid · HIPAA Compliant · LUCA LLC RCM
Every patient episode follows this exact sequence. No stage is skippable.
| From Stage | To Stage | Gate Requirement | Consequence of Skipping |
|---|---|---|---|
| 1 → 2 | Auth/F2F | Eligibility confirmed in portal. Screenshot saved. | Unbillable episode — full write-off risk |
| 2 → 3 | OASIS | Auth confirmed (managed care). F2F in process or on file. | NOA and final claim denial |
| 3 → 4 | NOA | OASIS-E SOC signed in Synergy and submitted to iQIES. | $50/day penalty accumulates from SOC date |
| 4 → 6 | Final Claim | NOA confirmed ACCEPTED at CGS. (Not just submitted — accepted.) | Final claim will be denied — linked to NOA |
| 5 → 6 | Final Claim | All visit notes signed and locked in Synergy. LUPA threshold met or documented. | Claim rejection, audit risk |
| 6 → 9 | A/R | ERA posted and reconciled. Denials routed to Stage 8. | A/R distortion, revenue leakage |
All active payers, billing contacts, auth rules, and timely filing limits.
| Payer | Type | Auth Required | Billing Channel | Timely Filing | Key Rules |
|---|---|---|---|---|---|
| Medicare Part A (FFS) | Federal — Traditional Medicare | NO — FFS | CGS DDE / Waystar → Jurisdiction J (J15) | 12 months from SOC | NOA within 5 days. PDGM payment model. F2F mandatory. |
| Colorado Medicaid / HCPF | State Medicaid | YES — prior auth | Waystar → Colorado HCPF / Health First Colorado | 12 months from DOS | EVV mandatory (Sandata). Per-visit rates. Homebound NOT required for personal care. |
| RMHS (Rocky Mountain Human Services) | CO Medicaid CCB — IDD Population | YES — RMHS case manager | Waystar → Colorado Medicaid (RMHS auth number on claim) | 12 months from DOS | Anonymized patient IDs: RMHS_RPF_ID XXXXXXXX. EVV mandatory. Auth from RMHS case manager only. |
| Humana (Medicare Advantage) | Medicare Advantage Plan | YES — required | Availity → Humana EDI | Per contract terms | Monthly auth verification (Section 30). Track expiry in column date_mm208z42. Do NOT serve without confirmed auth. |
| Aetna (Medicare Advantage) | Medicare Advantage Plan | YES — required | Availity → Aetna EDI | Per contract terms | Same rules as Humana. Auth end date tracked. Verify after every hospitalization. |
| Pinnacle Health Plan | Managed Care | YES — required | Per Pinnacle contract instructions | Per contract terms | Contract rate applies. Verify coverage scope includes home health disciplines ordered. |
| Private Pay | Self-Pay | N/A | Monthly invoice to patient/family | Upon invoice (net 30) | Signed financial agreement required before SOC. Collections handled by VERA after 60 days. |
Continue services as planned. No action needed beyond monthly verification at Section 30.
HAVEN initiates renewal request with payer immediately. Do NOT wait for expiration. Services cannot be billed after auth expiry without a new authorization number.
STOP services immediately. Contact payer for emergency retroactive auth. If retro-auth denied: evaluate whether continued services create agency financial liability. Escalate to Samuel within 2 hours of discovery.
After ANY hospitalization: re-verify auth before resuming services. Managed care payers often require a new auth after inpatient admission. APEX handles hospital discharge tracking (Section 31 in patient board).
Patient-Driven Groupings Model — Medicare home health payment since January 1, 2020
| # | Factor | Options | How It Affects Payment | Billing Action |
|---|---|---|---|---|
| 1 | Timing | Early (1st 30 days) vs. Late (2nd 30 days) | Early pays more. Start care promptly to maximize early period. | Track episode start date accurately in Synergy |
| 2 | Admission Source | Community vs. Institutional (hospital/SNF within 14 days) | Institutional source pays more. Document discharge source accurately. | Verify referral source documentation at intake |
| 3 | Clinical Grouping | 12 clinical groups based on primary ICD-10-CM diagnosis | Primary diagnosis drives the group and the base payment. Wrong code = wrong payment. | CODA reviews every primary diagnosis before claim submission |
| 4 | Functional Level | Low / Medium / High (from OASIS functional items) | Higher functional level = higher payment. OASIS accuracy is critical. | CODA reviews OASIS functional items M1800–M1870 |
| 5 | Comorbidity Adjustment | None / Low / High (from secondary diagnoses) | More comorbidities = higher payment. Code all active secondary diagnoses. | CODA codes all secondary diagnoses supported by physician orders |
Visits can ONLY be added to prevent a LUPA if they are clinically justified by the patient's condition and physician orders. Adding visits purely to avoid LUPA — without clinical justification — constitutes Medicare fraud. Document every additional visit with specific clinical rationale in the visit note.
Stage 8 — Every denial is investigated. Every recoverable dollar is pursued.
| Code | Meaning | Action Required | Priority |
|---|---|---|---|
| N688 | Face-to-face not on file or insufficient | Obtain updated F2F from physician. Submit with Level 1 appeal. | HIGH |
| N657 | Homebound status not documented | Pull visit notes with homebound language. Appeal with 5-note sample. | HIGH |
| CO-167 | OASIS not on file at CMS | Check iQIES. Resubmit OASIS-E if missing. Attach confirmation to appeal. | MEDIUM |
| CO-16 / MA130 | Claim lacks required information | Identify missing field. Correct and resubmit same day. | MEDIUM |
| AUTH Denial | No valid authorization (managed care) | Contact payer immediately. Request retroactive auth if clinically justified. | HIGH |
| CO-4 / CO-5 | Procedure/modifier inconsistency | CODA review — recode and resubmit with corrected codes. | MEDIUM |
| PR-96 | Non-covered — ABN required | Verify ABN was issued before service. If not issued: agency liable. | HIGH |
| CO-97 | Payment included in prior claim | Review for bundling issue. Verify original claim was not already paid. | LOW |
| Level | Name | Reviewer | Filing Deadline | Decision Timeline |
|---|---|---|---|---|
| Level 1 | Redetermination | MAC (CGS) | 120 days from denial (LUCA SLA: 30 days) | 60 days for decision |
| Level 2 | Reconsideration | QIC (Qualified Independent Contractor) | 180 days from Level 1 denial | 60 days for decision |
| Level 3 | ALJ Hearing | OMHA Administrative Law Judge | 60 days from Level 2 denial | 90 days for decision |
| Level 4 | Appeals Council Review | DAB Medicare Appeals Council | 60 days from Level 3 denial | 90 days for decision |
| Level 5 | Federal District Court | U.S. District Court | 60 days from Level 4 | Indeterminate |
ARIA delivers the Monthly Billing Operations Report by the 5th business day of each month.
| A/R Age | Status | Required Action | Owner |
|---|---|---|---|
| 0–30 days | Current | Normal processing window. No action needed. | ARIA monitors |
| 31–60 days | Follow-Up | Verify claim received and in process at payer. Call if no ERA received. | ARIA contacts payer |
| 61–90 days | Active Pursuit | Call payer to confirm status. Re-submit if not on file. Log every contact. | ARIA — escalated action |
| 91–120 days | Escalated | Escalate to Samuel. File appeal or resubmit immediately. Daily monitoring. | ARIA → Samuel |
| 120+ days | Critical | File appeal immediately. Evaluate write-off candidacy. Samuel final approval required for write-off. | Samuel decision required |