Recommended Billing Process
Horizon's Provider Management is a powerful billing system. In order for the billing features and processes to work properly, the following weekly billing process should be followed. This section provides a general overview the suggested billing process in the Stratus ID Cloud. For purposes of this training, we are using PROMISe as the payor; however, the system can process billing for any insurance company.
Every organization has different processes for service documentation and billing. Sometimes in a smaller organization, one person may be responsible for the entire billing process while in a larger organization, several people will complete different steps of the process.
It's important to note that these written directions list the payor as PROMISe. If you are billing a different insurance company, select that company instead of PROMISe.
MONDAY
Trade File Import
PROMISe will issue a weekly trade file the Monday after the billing was submitted. After you download and save the trade file from the PROMISe website, it can be imported into the system and generate a report to show what claims were paid, amount paid, denied claims, etc.
It is very important to download trade files weekly. If you submit billing MONTHLY, remember to download/import trade files every Monday. You will need to manually download/save the trade files from PROMISe every Monday. Trade files are available for two weeks after the date of issue and then archived. You can request a copy of the trade file for two more weeks and then the trade file is deleted.
After the Trade File is imported, review the Service Detail by Promise Status Report report. This report will give you a listing of where each claim stands. Our goal is to get them to the PAID status (Approved for Payment). If this report is reviewed each week for the prior week billing, you can stay on top of all billed/not billed and denied claims.
Process 835 Files
Approximately three weeks after PROMISe billing was submitted, the 835 file is issued on the state BBS Business Exchange Services website. This file is the reconciliation report for the billing period. The actual payment is typically received about the same time as this report.
The Create Accounts Receivable process needs run BEFORE the 835 files are processed.
Process Cash Receipts
The downloaded 835 files will be in the Cash Receipt Entry. Review and post the cash receipts.
TUESDAY
HCSIS Compare
The HCSIS Compare process will review the consumer information in Provider Management and in HCSIS. This includes the facility/location, service authorizations, units, effective dates, and rates.
If there is any difference in the information in HCSIS and the system, the report will show each item that doesn't match. Differences should be reviewed and corrected before the billing is submitted.
See HCSIS Compare
WEDNESDAY
Billing Preparation
REQUIRED STEP: The Unauthorized Service Listing step is REQUIRED to mark services to pull into the EDI billing file. If you do not run this report, your EDI edit list and billing file will not include any billing.
Review Services
Review the services entered in the system.
See Service Detail Report, Missing Residential Services List, Documentation to Billing
Unauthorized Service Listing
This process will review all services entered in the system to make sure there is a service authorization/available units. Any service without an authorization will be listed on this report.
If all billable services are authorized and have enough units to bill, the report will be blank.
REQUIRED STEP: This step is required to mark services to pull into the EDI billing file. If you do not run this report, your EDI edit list and billing file will not include any billing.
See Unauthorized Service Listing
Revenue Reconciliation Report
This report will give you the total amount of revenue that will be posted after the billing process is complete.
The total (after amounts already in AR) should match the Posting Report from the Create Accounts Receivable step. Save this report for future reference and comparison.
EDI Billing Process
This process creates the billing file (837) that gets uploaded to PROMISe. Make sure to use the same parameter selections as used for the EDI Billing Edit List. After this file is created and saved to your computer, you will need to log into the Web BBS Business Exchange Services website to upload the file.
When processing billing, the total amount on the EDI Edit List should always equal the amount listed on the EDI Billing File and EDI Billing Verification.
REQUIRED STEP: This process is required to prepare the billing file that will be submitted to PROMISe through the Web BBS Business Exchange Services website. After this file is created and saved to your computer, you will need to log into the Web BBS Business Exchange Services website to submit the new file.
Create Accounts Receivable
This process will create aged accounts receivable and post the detail to history for all claims. If you do not use the Horizon financial package, this process will provide you with the information to record revenue in your general ledger.
Make sure AR is created after you submit your EDI billing file or 835 files will not process properly. Creating AR is required for processing voids and adjustments.
See Create AR
THURSDAY
Payment Applications
The final step in the billing process will ensure the payment is applied to the consumer/unpaid claim in the system.
After you download/process 835 files and post cash receipts, the system will automatically apply payments to open claims. If a payment does not automatically clear, you will need to manually link the 835 payment to the service.
7/2023