PMPM Visits

PMPM Workflow

PMPM is now live (08/30/2024).  Visiting Aid will be hosting a webinar on September 3rd, 2024 to review the workflow. 

PMPM Setup Reminder

1)  Visit Types and PMPM Setting

Visiting Aid has added the PMPM click been updated to allow agency used to select PMPM for all visit types that will now include monthly PMPM billing (in addition to unit / hour rates).

After selecting the PMPM Applicable for the visit type, a second window appears.  This window allows the use to determine the PMPM setting for the visit type (authorized hours or utilized).  By default, the system will show Utilized Hours. 

There are some payers and program that process PMPM billing based on authorized hours, but most MLTCs is basing the PMPM billing on utilized hours.

2)  Verify Procedure Code and Revenue Code

The rollout of this process with the MLTCs has been very sloppy.  Some MLTCs are using the state defaults for procedure and revenue code, while other MLTCs require different procedure codes.  This step is critical to ensure payment is timely. 

Example:

  a)       Anthem

b)       Elderplan

3)  Creating PMPM Visits

a.   Billing-> PMPM Tab:  Under the billing tab, there is a separate section for creating PMPM billable visits.  Select Year, Select Month, Select Contractor, Click Search

b.   Review Data: The data will be presented so all users can see authorized hours and utilized hours.  PMPM billing (most MLTCs) is based on utilized hours.  It’s critical for the coordination team to get all timesheets in the system as soon as possible.  The billing team will need to process billing for a visit to be considered utilized. 

i.      Agency users can select the patients that are ready for billing and deselect those that are still pending.

ii.      The History Section will show all PMPM visits that have been created.  Patient names will still appear in the create visit section until a PMPM visit has been created. 

iii.      Export Dropdown -> Visit Summary can be used to see totals prior to visit creation.

Create Visits Sample

Visit Summary Sample 

PMPM History Sample

PMPM History Specific Sample

Patient Calendar Sample

Visit Screen Sample

4)  Creating Billing File

a.       Billing Creation follows the same workflow as normally Visiting Aid billing.  Once the visits are created, navigate to the Billing-> Creating-> Ready for Submission.

i.      Since regular visits are PMPM visits cannot be included in the same billing batch, a drop down was added to this section for PMPM Services

  b.       Best Practices

i.      Review Data.  After click search, please have your team review the data to ensure accuracy.

ii.      Review Export / Visit Summary.   Always click the drop down next to the export button to view the visit summary prior to processing.

5)  Submission Batches

a.       All PMPM submission batches are stored under the submission batches tab.  Agency use can sort to show on PMPM Batches

b.       Best Practices

i.      Add Comments to help track submission and other details.

ii.      Visiting Aid always recommends link Visiting Aid to the Clearinghouse.  The Submit button track claim upload.