Betasky

Chapter 30: Complete Patient Journey Workflow

Overview

This chapter walks you through the complete lifecycle of a patient in the system, from the moment they're admitted to your agency until final payment is received. This end-to-end workflow demonstrates how all modules work together to deliver care and ensure proper reimbursement.

Purpose: Show the complete patient journey based on how the system ACTUALLY works, not assumptions.

The Patient Journey: Maria's Story

Let's follow Maria Rodriguez, a 72-year-old Medicare patient with diabetes and hypertension, through her entire home health episode.

Phase 1: Referral & Setup (Before Admission)

Step 1: Add Referring Physician (Physicians/Sources Management)

What Happens:

  • Dr. Smith's office calls with a referral for Maria
  • Administrator adds Dr. Smith to the system

In the System:

  • Go to: Physicians/Sources Management (Chapter 28)
  • Click: + Add Physician
  • Can search CMS NPI registry and import his data automatically
  • Or manually enter: Name, NPI, address, phone
  • Save

Result: Dr. Smith is now in the system and can be selected as certifying physician.

Phase 2: Patient Admission (Day 1)

Step 2: Complete Patient Admission Form (Patient Intake)

What Happens:

  • Admissions coordinator opens patient admission form
  • Fills out ALL 9 tabs of information
  • System automatically creates Care Order, Plan of Care, and OASIS SOC visit

In the System (Patient Intake - Chapter 14):

Click: Patients → + Add Patient

Tab 1: Demographics

  • First Name: Maria
  • Last Name: Rodriguez
  • Date of Birth: 05/15/1952
  • Gender: Female
  • SSN: 123-45-6789
  • Phone: (512) 555-1234
  • Address: 123 Oak Street, Austin, TX 78701
  • Start of Care Date: 02/10/2026 ⭐ (CRITICAL - triggers auto-creation)
  • Assigned Clinician: Sarah Johnson, RN ⭐ (CRITICAL - becomes case manager)

Tab 2: Payer Information

  • Primary Payer: Medicare of Texas
  • Medicare Number: 123456789A

Tab 3: Physician Information

  • Ordering Physician: Dr. John Smith (from dropdown)

Tab 4: Clinical/Diagnosis

  • Primary: E11.9 - Type 2 diabetes mellitus
  • Secondary: I10 - Hypertension

Tab 5: Pharmacy

  • Preferred Pharmacy: CVS Pharmacy

Tabs 6-8: Complete Emergency Contacts, Emergency Preparedness, Advanced Directives

Tab 9: Referral Information

  • Referral Source: Memorial Hospital
  • Certifying Physician: Dr. John Smith ⭐ (CRITICAL - triggers auto-creation)
  • Referral Date: 02/08/2026

Click: Complete Admission

What the System Does AUTOMATICALLY (behind the scenes):

  1. Creates Patient record (status: "PENDING")
  2. Creates IntakeData record (stores all 9 tabs)
  3. BECAUSE we provided startOfCareDate (02/10/2026) + certifyingPhysicianId (Dr. Smith) + caseManagerId (Sarah Johnson):

    • ✅ Auto-creates Care Order

      • Patient: Maria Rodriguez
      • Physician: Dr. John Smith
      • Case Manager: Sarah Johnson, RN
      • Start Date: 02/10/2026
      • End Date: 04/10/2026 (60 days)
      • Reason: "New Admission"
      • Status: "Pending Assessment"

    • ✅ Auto-creates Plan of Care

      • Care Order: (linked to above)
      • Status: "DRAFT"

    • ✅ Auto-creates OASIS SOC Compliance Task

      • Type: "OASIS_ASSESSMENT"
      • Due Date: 02/15/2026 (5 days from start)
      • Assigned To: Sarah Johnson, RN
      • Status: "PENDING"

    • ✅ Auto-creates OASIS SOC Visit

      • Patient: Maria Rodriguez
      • Visit Type: OASIS Start of Care
      • Scheduled Date: 02/10/2026
      • Assigned To: Sarah Johnson, RN
      • Status: "Scheduled"
      • Linked to compliance task

    • ✅ Updates Compliance Task

      • Status: "PENDING" → "SCHEDULED"
      • Links to visit

Result: Patient is admitted! Care Order, Plan of Care, and OASIS SOC visit are all created automatically. Sarah sees the OASIS visit in her schedule.

Phase 3: OASIS Start of Care Assessment (Days 1-3)

Step 3: Clinician Completes OASIS SOC (My Schedules)

What Happens:

  • Sarah visits Maria at home on Day 3 (02/12/2026)
  • Completes comprehensive OASIS assessment
  • Documents medications, diagnoses, functional status, and Plan of Care frequencies

In the System:

Sarah's Workflow (My Schedules - Chapter 9):

  1. Opens: My Schedules on her tablet
  2. Sees: "Maria Rodriguez - OASIS Start of Care, 10:00 AM"
  3. Clicks: Start Visit (checks in)
  4. Fills out OASIS form (Chapter 20) - all sections:
    • Patient demographics and payer info
    • Diagnoses, medications, therapies
    • Functional status (ADLs, mobility, etc.)
    • Plan of Care section (CRITICAL):
      • SN (Skilled Nursing): 3x/week x 4 weeks, then 2x/week x 4 weeks
      • HHA (Home Health Aide): 3x/week x 8 weeks
    • Medication Profile:
      • Metformin 500mg BID
      • Lisinopril 10mg daily
      • Aspirin 81mg daily
  5. Before submitting, clicks: Check for Errors (QA Review button)
    • System runs CMS validation
    • Shows any CMS Fatal Errors (must fix)
    • Shows CMS Warnings (advisory)
    • Shows Clinical Plausibility Alerts (soft alerts)
  6. Reviews results:
    • Fixes any CMS Fatal Errors (blocks submission if present)
    • Reviews soft alerts, fixes if needed (doesn't block submission)
  7. Clicks: Submit to QA

Result: OASIS status → "Pending Review". QA team receives notification.

Phase 4: QA Review & Approval (Days 4-5)

Step 4: QA Reviews OASIS (QA Center)

What Happens:

  • QA Reviewer checks OASIS for errors
  • Runs CMS validation
  • Approves if no fatal errors

In the System (QA Center - Chapter 21):

  1. Go to: QA Center
  2. See: Maria Rodriguez - OASIS SOC - Pending Review
  3. Click: Review
  4. Click: Check for Errors (runs CMS validation)
    • System checks for CMS Fatal Errors (block submission)
    • System checks for CMS Warnings (advisory)
    • System runs Clinical Plausibility Alerts (soft alerts)
  5. Review results: 1 warning (acceptable - wound documented as healing)
  6. Add note: "Wound healing well, RN monitoring"
  7. Click: Approve

What the System Does:

  • OASIS SOC status → "Pending Physician Signature" (because SOC requires signature)
  • Plan of Care status → "PENDING_SIGNATURE"
  • Care Order status → "Pending Physician Signature"
  • OASIS Submission created (status: "READY_TO_SUBMIT")

Result: OASIS waiting for physician signature.

Phase 5: Physician Signature & Activation (Day 6)

Step 5: Physician Signs Plan of Care

What Happens:

  • Dr. Smith receives email notification
  • Reviews and signs Plan of Care electronically

In the System:

  • Dr. Smith receives secure email link
  • Logs in to physician portal
  • Reviews Maria's OASIS Plan of Care
  • Enters password
  • Clicks: Sign

Result: Physician signature captured. Now administrator can mark as active.

Step 6: Administrator Marks OASIS as Active (Critical Step!)

What Happens:

  • Administrator sees OASIS with physician signature
  • Clicks "Mark as Active"
  • THIS IS WHERE THE MAGIC HAPPENS - system creates PA, activates episode

In the System (QA Center):

  1. Go to: QA Center → Pending Physician Signature tab
  2. See: Maria Rodriguez - OASIS SOC - Signed by Dr. Smith
  3. Click: Mark as Active
  4. Confirm

What the System Does AUTOMATICALLY (the big activation moment):

  1. Creates Prior Authorization (from OASIS frequencies):

    • Patient: Maria Rodriguez
    • Payer: Medicare of Texas
    • Care Order: (linked)
    • Source Document: OASIS SOC
    • Start Date: 02/10/2026
    • End Date: 04/10/2026
    • Lines:
      • SN: 20 requested units (3x4 + 2x4 = 20 visits)
      • HHA: 24 requested units (3x8 = 24 visits)
    • Status: "pending"

  2. IF Medicare (Maria is Medicare):

    • Auto-approves PA:
      • Status: "pending" → "approved"
      • Approved units = Requested units (SN: 20, HHA: 24)
    • Calculates HIPPS code (Medicare billing code):
      • Uses OASIS answers to calculate HIPPS
      • Stores on Care Order: 1CBFD (example)

  3. Updates statuses:

    • OASIS document status → "Approved"
    • Care Order status → "Active" ⭐
    • Plan of Care status → "ACTIVE" ⭐
    • Patient status → "ACTIVE" ⭐

  4. Creates Medication Snapshot (frozen copy of meds at this moment)

  5. Completes compliance task (OASIS_ASSESSMENT → "COMPLETE")

Result: Episode is NOW officially open and billable! PA is approved. Maria is active patient.

IMPORTANT: Visits are NOT auto-generated at this stage. They must be created manually (next step).

Phase 6: Generate Visits from PA (Day 6)

Step 7: Generate Visits from Approved PA (Prior Authorizations)

CRITICAL UNDERSTANDING: This is where the workflow differs significantly based on payer type. Understanding this section is key to knowing why visits appear or don't appear in your schedule.

What Happens:

  • FOR MEDICARE: PA is auto-approved when marked active → can generate visits immediately
  • FOR PRIVATE INSURANCE: PA created with status "pending" → administrator must manually call insurance, get approval, update PA in system, THEN generate visits
  • FOR PATIENTS WITHOUT INSURANCE: Warning shown, PA created with NULL payer → visits created as non-billable (cannot bill for them)

Why This Matters:

  • Medicare trusts agencies to bill correctly, so they approve automatically
  • Private insurance requires pre-approval before authorizing visits
  • Patients without insurance can still receive care, but agency cannot bill for services

SCENARIO A: MEDICARE PATIENT (like Maria)

Context: Medicare operates on a trust-based system. When you mark an OASIS SOC as active, Medicare automatically approves all requested units because they trust your clinical judgment. You'll bill them later using HIPPS codes based on the patient's clinical grouping.

What System Does When Marked Active (Phase 5, Step 6):

  • Creates PA from OASIS Plan of Care frequencies
  • Auto-approves immediately (no insurance call needed):
    • Status: "pending" → "approved"
    • Authorization number: Auto-generated (system-generated ID)
    • Approved units = Requested units (exactly what you asked for)
      • SN: Requested 20 → Approved 20 ✅
      • HHA: Requested 24 → Approved 24 ✅
  • Calculates HIPPS code for billing (e.g., 1CBFD)
  • Care Order → "Active"
  • Patient → "ACTIVE"

Administrator Generates Visits (same day, immediately):

In the System (Prior Authorizations - Chapter 24):

  1. Go to: Prior Authorizations

  2. Click: Maria Rodriguez's PA

  3. See Status: "approved" ✅ (auto-approved by system for Medicare)

  4. See Authorization Number: PA-2026-00123 (auto-generated)

  5. See Service Lines table with ALL units approved:

    DisciplineRequestedApprovedUsedRemaining
    SN2020 ✅020
    HHA2424 ✅024

  6. Click: Generate 20 Missing Visits (for SN)

    • System creates 20 SN visits
    • All unassigned (no clinician yet)
    • Spread evenly across 60 days (certification period)
    • All marked as billable

  7. Click: Generate 24 Missing Visits (for HHA)

    • System creates 24 HHA visits
    • All unassigned
    • Spread evenly across 60 days
    • All marked as billable

Result: 44 total visits created (20 SN + 24 HHA). All visits appear in Schedule Center's "Needs Scheduling" sidebar, ready to be assigned to clinicians.

Key Point: For Medicare, this is a same-day process. No waiting for insurance approval. Mark as active → immediately generate visits → schedule them.

SCENARIO B: PRIVATE INSURANCE PATIENT (Blue Cross Blue Shield)

Context: Private insurance companies want to control costs, so they require pre-authorization before allowing visits. This is a multi-day process involving phone calls, faxes, and back-and-forth with insurance. The insurance company may approve fewer visits than you requested to save money.

If Maria had Blue Cross Blue Shield (private insurance) instead of Medicare:

What System Does When Marked Active (Phase 5, Step 6):

  • Creates PA from OASIS Plan of Care frequencies
  • Does NOT auto-approve (private insurance must approve manually)
  • Status: "pending" ⏳ (waiting for insurance review)
  • Approved units: 0 for all lines (insurance hasn't approved anything yet)
  • Care Order → "Active" (patient can receive care)
  • Patient → "ACTIVE" (episode is open)

Administrator Checks PA (Day 6 - immediately after marking active):

In the System (Prior Authorizations - Chapter 24):

  1. Go to: Prior Authorizations

  2. Click: Maria Rodriguez's PA

  3. See Status: "pending" ⏳ (waiting for insurance approval - this is NORMAL for private insurance)

  4. See Authorization Number: (blank - insurance hasn't provided one yet)

  5. See Service Lines table with NO approved units:

    DisciplineRequestedApprovedUsedRemaining
    SN200 ❌00
    HHA240 ❌00

  6. Cannot generate visits yet - "Generate Missing Visits" buttons are disabled or will create 0 visits (no approved units to generate from)

Administrator's Real-World Process (Days 6-10 - this takes time!):

Day 6 - Submit to Insurance:

  1. Administrator calls Blue Cross Blue Shield prior authorization department
  2. Provides patient info, diagnosis, OASIS assessment findings
  3. Reads Plan of Care frequencies:
    • "We're requesting 20 skilled nursing visits over 60 days"
    • "We're requesting 24 home health aide visits over 60 days"
  4. Insurance says: "We'll review and call back in 3-5 business days"

Day 7-9 - Waiting:

  • Insurance company reviews medical necessity
  • May call doctor's office for records
  • May request additional clinical documentation
  • Administrator checks daily for update

Day 10 - Insurance Approves (with reductions):

  • Insurance calls back with decision
  • Authorization Number: AUTH-BCBS-123456
  • SN: Approved 15 visits ❌ (Denied 5 visits - insurance says "15 is medically necessary, 20 is excessive")
  • HHA: Approved 20 visits ❌ (Denied 4 visits - insurance says "20 is sufficient")

Administrator Updates PA with Insurance Approval (Day 10):

In the System (still on PA detail page): 7. Click: Edit PA (pencil icon at top right) 8. Edit Prior Authorization Modal opens:

Main Section:

  • Status: "pending" → "approved" ✅ (MUST change this)
  • Authorization Number: AUTH-BCBS-123456 (REQUIRED - system won't let you save "approved" status without this)

Service Lines Section (table with each discipline):

DisciplineRequestedApproved Units (Edit)Reason
SN2015 ⬅️ (enter what insurance approved)Insurance approved 15, denied 5
HHA2420 ⬅️ (enter what insurance approved)Insurance approved 20, denied 4
  1. Click: Save

What System Does Automatically (behind the scenes):

  • Updates PA status to "approved"
  • Saves authorization number
  • Updates approved units for each discipline line
  • Auto-links any existing unlinked visits (if any visits were already created before approval, system now links them to this PA)
  • Recalculates authorization alerts (checks if existing visits are within limits)
  • Triggers notification that PA is approved

Administrator Generates Visits (Day 10 - now that PA is approved):

In the System (refresh or navigate back to PA): 10. Refresh page or click back to PA detail 11. See Status: "approved" ✅ (changed from "pending") 12. See Authorization Number: AUTH-BCBS-123456 (saved) 13. See updated Service Lines table with insurance-approved units:

| Discipline | Requested | Approved | Used | Remaining |
|------------|-----------|----------|------|-----------|
| SN         | 20        | **15** ⚠️ | 0    | 15        |
| HHA        | 24        | **20** ⚠️ | 0    | 20        |

14. Click: Generate 15 Missing Visits (for SN - notice it's 15, not 20!) - System creates only 15 SN visits (what insurance approved) - All unassigned - Spread across 60 days - All marked as billable

  1. Click: Generate 20 Missing Visits (for HHA - notice it's 20, not 24!)
    • System creates only 20 HHA visits (what insurance approved)
    • All unassigned
    • Spread across 60 days
    • All marked as billable

Result: 35 visits created (15 SN + 20 HHA) - based on what insurance approved, not what was requested.

Key Differences vs Medicare:

  1. Time: Medicare = same day, Private = 3-10 days waiting
  2. Approved Amount: Medicare = 100% approved, Private = often reduced (in this case, only 79% approved: 35/44 visits)
  3. Manual Work: Medicare = automatic, Private = requires phone calls, documentation, updates
  4. Risk: With Medicare you get what you ask for; with private insurance you might need to re-request if patient needs more visits later

What If Insurance Denied Completely?

  • Administrator would update status to "denied" instead of "approved"
  • Add denial reason (e.g., "Insurance says home health not medically necessary")
  • Cannot generate any visits
  • Would need to appeal or patient pays out-of-pocket

SCENARIO C: PATIENT WITHOUT INSURANCE (Self-Pay)

Context: Some patients don't have insurance (uninsured, waiting for Medicare eligibility, dropped coverage, etc.). Your agency can still provide care for compassionate or business reasons, but you cannot bill anyone for these visits. These visits are tracked but marked as non-billable.

If Maria had NO primary insurance (no Medicare, no private insurance):

What System Does When Marked Active (Phase 5, Step 6):

BEFORE marking active, system shows WARNING:

┌─────────────────────────────────────────────────────┐
│  ⚠️  Patient Has No Primary Insurance                │
├─────────────────────────────────────────────────────┤
│                                                      │
│  This patient has no primary insurance assigned.    │
│                                                      │
│  If you continue:                                   │
│  • Prior Authorization will be created with no payer│
│  • All visits will be marked as non-billable        │
│  • Visits will NOT appear in Claims Center          │
│  • No Medicare/Medicaid billing possible            │
│  • Agency will not be reimbursed for services       │
│                                                      │
│  You can update patient insurance later and do a    │
│  Recertification to create a new billable episode.  │
│                                                      │
│  [Cancel]  [Continue Anyway] ← Requires confirmation│
└─────────────────────────────────────────────────────┘
  • Administrator reads warning
  • Understands agency won't be paid for these visits
  • Clicks: Continue Anyway (maybe patient will get insurance later, or agency provides charity care)

System Proceeds (after confirmation):

  • Creates PA from OASIS frequencies
  • Creates with NULL payerId (no payer attached to this PA)
  • Status: "pending" (will stay pending - cannot be approved without payer)
  • Approved units: 0 (no insurance to approve)
  • All future visits from this PA will be flagged as isBillable: false
  • Care Order → "Active"
  • Patient → "ACTIVE"

Administrator Generates Visits (Day 6):

In the System (Prior Authorizations - Chapter 24):

  1. Go to: Prior Authorizations

  2. Click: Maria Rodriguez's PA

  3. See Status: "pending" ⏳ (will stay pending forever without insurance)

  4. See Payer: (None) ❌ - no payer assigned to this authorization

  5. See Authorization Number: (blank - no insurance to provide one)

  6. See Service Lines table:

    DisciplineRequestedApprovedUsedRemaining
    SN20000
    HHA24000

  7. Special Case: System allows generating visits even though PA is not approved (normally blocked, but exception for NULL payer):

    • Click: Generate 20 Missing Visits (SN)
    • Click: Generate 24 Missing Visits (HHA)

  8. All 44 visits created BUT marked as NON-BILLABLE:

    • SN: 20 visits created, isBillable: false ❌
    • HHA: 24 visits created, isBillable: false ❌
    • Visits appear in Schedule Center (can be scheduled normally)
    • Clinicians can complete visits normally
    • QA can approve visits normally
    • BUT: These visits will NEVER appear in Claims Center
    • AND: These visits CANNOT be added to any claim

Result: 44 visits created but all non-billable. Maria can receive full care, but agency will not receive any reimbursement. Clinicians won't see any difference (visits look normal to them), but billing team will never see these visits.

What Clinicians See (no difference for them):

  • Visits appear in their schedule normally
  • They complete visits normally
  • They submit to QA normally
  • They don't know these are non-billable (that's a billing department concern)

What Billing Department Sees:

  • These visits do NOT appear in "Ready for Billing" list
  • Cannot add to claims
  • Cannot bill for them
  • Shows $0.00 revenue potential

If Insurance Is Added Later (e.g., Day 30, Maria gets Medicare):

  1. Administrator updates patient's primary payer to Medicare
  2. Must complete new OASIS Recertification to create new billable episode
  3. Old episode (Days 1-30) remains non-billable forever (cannot retroactively bill)
  4. New episode (Days 31-90) will be billable with new PA
  5. Agency loses revenue for first 30 days but can bill for remaining days

When Would You Do This?

  • Patient promises insurance is "in process"
  • Compassionate care for terminally ill patient
  • Charity care program
  • Patient will pay out-of-pocket (tracks visits but doesn't bill insurance)
  • Emergency situation, can't wait for insurance

Result: 44 visits created but all non-billable. Patient can receive care but agency cannot bill for it.

If Insurance Added Later:

  • Administrator can update patient's primary payer
  • Must complete OASIS Recertification to create new billable episode
  • Old episode remains non-billable

Phase 7: Schedule Visits (Days 6-60)

Step 8: Scheduler Assigns Visits (Schedule Center)

What Happens:

  • Scheduler opens Schedule Center
  • Drags unassigned visits from sidebar to calendar
  • Assigns to clinicians

In the System (Schedule Center - Chapter 23):

  1. Go to: Schedule Center
  2. See left sidebar: "Needs Scheduling"
    • Maria Rodriguez - 20 SN visits (unassigned)
    • Maria Rodriguez - 24 HHA visits (unassigned)
  3. Drag visits from sidebar to calendar:
    • Week 1-4 (SN 3x/week):
      • Monday 10:00 AM → Sarah Johnson, RN
      • Wednesday 10:00 AM → Sarah Johnson, RN
      • Friday 10:00 AM → Sarah Johnson, RN
    • Week 1-8 (HHA 3x/week):
      • Monday 2:00 PM → Linda Martinez, HHA
      • Wednesday 2:00 PM → Linda Martinez, HHA
      • Friday 2:00 PM → Linda Martinez, HHA

Result: All visits scheduled and assigned. Sarah and Linda see visits in their schedules.

Phase 8: Clinicians Complete Visits (Days 7-60)

Step 9: Clinicians Document Visits (Visit Forms)

What Happens:

  • Each week, Sarah and Linda visit Maria
  • Document each visit
  • Submit to QA

Example: Sarah's SN Visit (Week 1, Monday):

In My Schedules (Chapter 9):

  1. Sarah opens: My Schedules
  2. Clicks: Start Visit on Maria's card
  3. Performs nursing assessment:
    • Takes vitals: BP 138/82, Glucose 145, Pulse 78
    • Educates on diabetes management
    • Reviews medications
  4. Opens: SN Visit Note form (Chapter 19)
  5. Documents:
    • Vital signs
    • Assessment: "Patient ambulating well, no SOB"
    • Skilled interventions: "Diabetes education, insulin training"
    • Plan: "Continue 3x/week per POC"
  6. Clicks: Submit to QA

Example: Linda's HHA Visit (Week 1, Monday afternoon):

  1. Linda opens: My Schedules
  2. Clicks: Start Visit
  3. Assists Maria with:
    • Bathing and grooming
    • Meal preparation
    • Light housekeeping
    • Medication reminders
  4. Opens: HHA Visit Note (Chapter 19)
    • System loads HHA Care Plan tasks automatically
    • Linda checks off completed tasks
  5. Documents narrative
  6. Clicks: Submit to QA

Result: Visit notes submitted to QA.

Step 10: QA Approves Visit Notes (QA Center)

What Happens:

  • QA reviews each visit note
  • Approves for billing

In the System (QA Center - Chapter 21):

  1. Go to: QA Center
  2. Review Sarah's SN Visit and Linda's HHA Visit
  3. No errors found
  4. Click: Approve Both

Result: Visits status → "Approved" (now billable). This continues for 8 weeks.

Phase 9: Billing - Period 1 Claims (After Day 30)

Step 11: Generate Claim for Period 1 (Claims Center)

What Happens:

  • After Day 30, administrator generates claim for Days 1-30
  • Medicare PDGM: 30-day billing periods

In the System (Claims Center - Chapter 25):

  1. Go to: Claims Center → Ready for Billing tab
  2. See: Maria Rodriguez - Medicare - 12 visits (Days 1-30)
    • Estimated: $3,200 (Medicare HIPPS flat rate)
  3. Click: Bill Patient
  4. Bill Patient Modal opens:
    • Patient: Maria Rodriguez
    • Payer: Medicare of Texas
    • Billing Period: Days 1-30
    • HIPPS Code: 1CBFD (from Care Order)
    • HIPPS Rate: $3,200.00
    • Visits: 12 visits listed (8 SN + 4 HHA)
    • Authorization: No alerts (Medicare doesn't need PA approval)
  5. Click: Generate Claim

Result: Claim created!

  • Claim Number: CLM-20260315-001
  • Total: $3,200.00
  • Status: "Ready to Submit"
  • All 12 visits now "locked" to this claim (can't be billed again)

Step 12: Submit Claim to Medicare (Claims Center)

What Happens:

  • Administrator exports claim as 837 EDI file
  • Submits to Medicare clearinghouse
  • Marks as submitted in system

In the System:

  1. Go to: Claims Center → Claims Tracking → Ready to Submit
  2. Click: Maria's claim
  3. Click: Export → 837P EDI
    • Downloads electronic file
  4. Submit file to Medicare clearinghouse (external system)
  5. Return to system
  6. Click: Mark as Submitted

Result: Claim status → "Submitted". Now wait 30-45 days for payment.

Phase 10: Payment Posting (45 days later)

Step 13: Receive Payment & Post to System (Payment Posting)

What Happens:

  • Medicare sends EFT for $3,200
  • Administrator posts payment to system

In the System (Payment Posting - Chapter 26):

Create Batch:

  1. Go to: Payment Posting
  2. Click: + Create Batch
  3. Fill:
    • Payer: Medicare of Texas
    • Payment Date: 04/25/2026
    • Method: EFT
    • Check Number: EFT123456
    • Total Amount: $3,200.00
  4. Click: Create

Add Claim: 5. Click: Select Claims 6. Filter: Medicare, Status = "Submitted" 7. Check: Maria Rodriguez - CLM-20260315-001 - $3,200.00 8. Click: Add Selected Claims

Review Batch: 9. See Balance Counter (top right):

  • Total to Apply: $3,200.00
  • Applied: $3,200.00
  • Remaining: $0.00 ✅ (Balanced!)
  1. Review claim in table:
    • Payment: $3,200.00
    • Adjustment: $0.00
    • Action: Pay

Post Batch: 11. Click: Post Batch 12. Confirm: "Are you sure? Cannot be undone." 13. Click: Confirm Post

What the System Does:

  • Batch status: "Draft" → "Posted" (immutable)
  • Claim status: "Submitted" → "Paid"
  • Claim balance: $3,200 → $0
  • Payment record created
  • Batch locked permanently

Result: Period 1 claim PAID! Revenue received.

Phase 11: Continue Care (Days 31-60)

Same process repeats:

  • Generate Period 2 claim (Days 31-60)
  • Submit to Medicare
  • Receive payment ($2,900 typical for Period 2)
  • Post payment

Total for First 60 Days: $6,100 ($3,200 + $2,900)

Phase 12: Recertification (Days 55-60)

Step 14: Complete OASIS Recertification

What Happens:

  • System auto-creates compliance task: "OASIS Recertification due"
  • Sarah completes recert assessment
  • Updates Plan of Care with new frequencies for next 60 days

Process (same as SOC):

  1. Scheduler assigns recert visit to Sarah (from compliance task)
  2. Sarah completes OASIS Recertification
  3. QA approves
  4. Dr. Smith signs
  5. Admin marks as active
  6. System creates NEW Care Order (Days 61-120)
  7. System creates NEW PA with new frequencies
  8. Auto-approves if Medicare
  9. Generate visits from PA
  10. Schedule visits

Result: Episode extended for another 60 days. Old Care Order expires automatically when Day 60 ends.

Phase 13: Discharge (Day 120)

Step 15: Complete OASIS Discharge

What Happens:

  • Maria has improved and is ready for discharge
  • Sarah completes OASIS Discharge assessment

In the System:

  1. Sarah completes OASIS Discharge form
    • Documents Maria's final status
    • Discharge disposition: "Discharged to community"
  2. QA approves (no physician signature needed for discharge)

What the System Does AUTOMATICALLY:

  • Care Order status → "Closed"
  • Patient status → "Discharged"
  • All future scheduled visits automatically cancelled
  • Prior Authorizations automatically closed
  • Episode officially ended

Result: Maria's episode complete! She's discharged.

Complete Revenue Summary

Maria's full 120-day episode generated:

PeriodDaysHIPPS RateRevenue
1st Cert - Period 11-30$3,200$3,200
1st Cert - Period 231-60$2,900$2,900
2nd Cert - Period 161-90$3,000$3,000
2nd Cert - Period 291-120$2,700$2,700
TOTAL$11,800

All claims submitted and paid. Episode complete. ✅

Journey Complete! 🎉

Maria successfully completed her home health episode:

✅ Admitted with auto-created Care Order and OASIS visit ✅ OASIS SOC completed, approved, and marked active ✅ PA auto-created and auto-approved (Medicare) ✅ Visits generated from PA and scheduled ✅ 92 visits completed (44 SN + 48 HHA) over 120 days ✅ Recertified for second 60-day period ✅ 4 claims generated and paid ($11,800 total) ✅ Discharged successfully, all future visits cancelled

Summary: The ACTUAL System Workflow

Here's what ACTUALLY happens (not assumptions):

Patient Admission (Chapter 14)

  • Fill out 9-tab admission form
  • IF form has startOfCareDate + certifyingPhysician + caseManager:
    • ✅ Care Order auto-created (status: "Pending Assessment")
    • ✅ Plan of Care auto-created (status: "DRAFT")
    • ✅ OASIS SOC compliance task auto-created (status: "PENDING")
    • ✅ OASIS SOC visit auto-created (status: "Scheduled")
    • ✅ Task updated to "SCHEDULED" (linked to visit)

OASIS SOC Completion (Chapters 9, 19, 20)

  • Clinician completes OASIS form
  • Submits to QA

QA Approval (Chapter 21)

  • QA reviews, runs validation
  • Approves → status: "Pending Physician Signature"
  • OASIS Submission created (status: "READY_TO_SUBMIT")

Physician Signature & Mark as Active (Chapter 21)

  • Physician signs electronically
  • Admin clicks "Mark as Active"
  • THIS IS THE BIG MOMENT:
    • ✅ PA created from OASIS frequencies
    • ✅ IF Medicare: PA auto-approved, HIPPS calculated
    • ✅ Care Order → "Active"
    • ✅ Patient → "ACTIVE"
    • ✅ Medication snapshot created
    • ⚠️ Visits NOT auto-generated (must be manual)

Visit Generation (Chapter 24)

  • Go to PA detail page
  • Click "Generate X Missing Visits" for each discipline
  • Visits created as "unassigned"

Visit Scheduling (Chapter 23)

  • Drag unassigned visits from sidebar to calendar
  • Assign to clinicians

Visit Documentation (Chapters 9, 19)

  • Clinicians complete visits
  • Submit to QA
  • QA approves → visits billable

Claims Generation (Chapter 25)

  • After 30 days, go to Claims Center
  • Click "Bill Patient"
  • System creates claim with HIPPS rate (Medicare) or fee schedule (private)
  • Export 837 EDI or CMS-1500 PDF
  • Submit to payer
  • Mark as submitted

Payment Posting (Chapter 26)

  • Receive payment (check/EFT)
  • Create remittance batch
  • Add claims to batch
  • Balance counter shows $0 remaining
  • Post batch → claims marked "Paid"

Recertification (Chapter 20)

  • System auto-creates compliance task
  • Complete OASIS Recert
  • QA approves, physician signs, mark as active
  • System creates NEW Care Order for next 60 days
  • Repeat visit generation/scheduling/billing

Discharge (Chapter 20)

  • Complete OASIS Discharge
  • QA approves
  • System closes Care Order, patient status, cancels future visits