When Do You Need an Authorization?

Whether an authorization is required depends on two factors:

1. Insurance Configuration

• If the insurance has "Authorization Required" = true, all visits need authorizations
• If "Authorization Required" = false, authorizations are optional but can still be used

2. Service Code Configuration

• Individual service codes can be marked as "Authorization Optional"
• This overrides the insurance requirement for that specific service
• Common for services like assessments or evaluations

Understanding Authorization Types at a Glance

Regular Authorizations

What they are: Standard approvals from insurance companies

How they work: Define units (hours/visits) that renew on a schedule (daily, weekly, monthly)

When to use: This is your primary, go-to authorization for all standard scheduling

System behavior: Automatically selected and applied when you create a visit

Accumulation Authorizations

What they are: Automatically calculated "rollover" units from unused regular authorization hours/visits

How they work: System tracks unused units from past periods and makes them available

When to use: When you've exhausted current week/month authorization but patient has accumulated unused units

System behavior: Must be manually selected; requires special permission ("CanUseAccumulatedAuthUnits")

Learn more: See the separate "Accumulation Authorization User Guide" for detailed explanation

Common Authorization Scenarios

Scenario 1: Simple Weekly Authorization

Setup: Authorization for 20 hours per week, Monday-Friday

What happens:

• Every Sunday, patient gets a fresh 20 hours for the new week
• Can schedule up to 20 hours total for that week
• System automatically selects this authorization when scheduling visits
• If you try to schedule more than 20 hours, you'll get a warning

Scenario 2: Day-Specific Authorization

Setup: Authorization for 4 hours on Mon, Wed, Fri only

What happens:

• Can only schedule on Monday, Wednesday, Friday
• Each allowed day can have up to 4 hours
• Try to schedule Tuesday? System shows error
• Try to schedule 5 hours on Monday? System shows error

Scenario 3: Overnight Visit Spanning Two Days

Setup: Visit from Saturday 10 PM to Sunday 6 AM (8 hours)

Problem: Saturday's weekly authorization only has 2 hours remaining

Solution: Split Billing

• Bill 2 hours to Saturday (uses last hours of this week)
• Bill 6 hours to Sunday (uses hours from next week)
• Contract must have "Allow Splitting Auths" enabled

Scenario 4: Running Out of Hours Mid-Week

Setup: Authorization for 40 hours/week, already used 40 hours by Thursday

What happens:

• Try to schedule Friday? System warns no hours available
• Option 1: Wait until Sunday when new week starts (40 fresh hours)
• Option 2: Use accumulation authorization if patient has accumulated units
• Option 3: Contact insurance for authorization increase

Scenario 5: Authorization Expires During Coverage Period

Setup: Auth #100 ends 1/31/2025, Auth #200 starts 2/1/2025

What happens:

• Visits in January automatically use Auth #100
• Visits in February automatically use Auth #200
• Overnight visit 1/31 11 PM - 2/1 7 AM? Use split billing with both authorizations

Regular Authorizations

Type Code: Regular (1)

Purpose: Standard authorizations that define the approved units (hours or visits) for a specific service code and time period.

Characteristics:

• Can be verbal or written
• Define specific periods (daily, weekly, monthly, or entire authorization period)
• Can specify different units for different days of the week
• Can have maximum unit caps for the entire authorization period
• Automatically selected for scheduling when available

Accumulation Authorizations

Type Code: Accumulation (2)

Purpose: Automatically calculated authorizations that track unused units from regular authorizations, allowing patients to "roll over" unused hours/visits.

Characteristics:

• Created and maintained automatically by the system
• Share the same authorization number as their regular authorization counterparts
• Require special permission to use ("CanUseAccumulatedAuthUnits")
• Units are recalculated weekly and when schedules change
• Always show minimum of 0 units (never negative)

When to use: When a patient needs extra hours/visits beyond their regular weekly/monthly allocation, and they have accumulated unused units from previous periods.

Unit Configuration

• Unit Type: Hours (H) or Visits (V)
• Units: Number of hours/visits allowed per period
• Period Type: Week (W), Month (M), Day (D), or entire Period (P)

Weekday Configuration

Controls which days of the week are allowed and how units are distributed:

• Weekdays UOM (Unit of Measure):
  • Day: Specific days selected (e.g., Mon, Wed, Fri)
  • Number: Any X days per week (e.g., any 5 days)
• Weekdays Value:
  • For "Day" UOM: Bitwise selection (1=Sun, 2=Mon, 4=Tue, 8=Wed, 16=Thu, 32=Fri, 64=Sat)
  • For "Number" UOM: Count of days allowed (e.g., 5)
• Weekdays Allowed to Vary: If true, can schedule on any day regardless of selection

Day-Specific Units (Weekly Authorizations)

For weekly authorizations, you can specify different units for each day:

• SunUnits, MonUnits, TueUnits, WedUnits, ThuUnits, FriUnits, SatUnits
• Example: Mon=4 hours, Tue=4 hours, Wed=2 hours, Thu=4 hours, Fri=4 hours

Maximum Units Cap

• MaxUnitsForAuthorization: Maximum total units allowed for the entire authorization period
• Example: Authorization is for 10 hours/week for 12 weeks, but max cap is 100 hours total
• System tracks "UnitsUsed" and validates against this cap

Step 1: Prevent Duplicate Authorization Usage

Rule: Each authorization can only be linked once per billing date

Why: Prevents accidentally billing the same authorization multiple times

Example of violation:

• Visit on 1/15/2025 has Auth #12345 linked twice
• System blocks this to prevent double-billing

Step 2: Validate Split Billing is Allowed

Rule: If billing date differs from schedule date, contract must allow split billing

Why: Split billing requires special contract configuration

Example of violation:

• Overnight visit: 1/15/2025 11 PM - 1/16/2025 7 AM
• Trying to bill different authorizations to each date
• Contract has "AllowSplittingAuths = false"

Step 3: Check Maximum Units for Authorization

Rule: Total units used cannot exceed MaxUnitsForAuthorization

Why: Authorization may have a lifetime cap regardless of period type

Example:

• Authorization: 10 hours/week for 12 weeks, Max: 100 hours total
• Already used: 95 hours
• Trying to schedule: 8 hours
• Result: FAIL (would exceed 100-hour cap)

Step 4: Validate Day of Week Allowed

Rule: Schedule date must fall on an allowed day of the week

Why: Authorization may restrict service to specific days

Example:

• Authorization: Mon, Wed, Fri only (Weekdays Value = 42)
• Trying to schedule: Tuesday visit
• Result: FAIL (Tuesday not allowed)

Exception: If "Weekdays Allowed to Vary" is true, any day is allowed

Step 5: Calculate Period Dates and Load Usage

What happens: System determines the relevant period and loads all usage for that period

Period calculation examples:

• Week: If scheduling on Wed 1/15/2025, period is Sun 1/12/2025 - Sat 1/18/2025
• Month: If scheduling on 1/15/2025, period is 1/1/2025 - 1/31/2025
• Day: If scheduling on 1/15/2025, period is just 1/15/2025
• Period: If auth is 1/1/2025 - 3/31/2025, entire period is used

Usage includes:

• Confirmed visits in the period
• Other scheduled visits in the period (if they count)
• Current visit being scheduled/edited

Step 6: Validate Hours Available (for Hourly Authorizations)

Rule: Total hours used + hours being scheduled cannot exceed authorized hours for period

Calculation:

Example:

• Authorization: 40 hours per month
• Period: January 2025
• Already used: 35 hours
• Available: 40 - 35 = 5 hours
• Trying to schedule: 8 hours
• Result: FAIL (need 8 hours, only 5 available)

Step 7: Validate 24-Hour Daily Cap

Rule: No single day can exceed 24 hours per authorization

Why: Physical impossibility - only 24 hours in a day

Additional check: Total hours for billing date across ALL authorizations cannot exceed 24 hours

Example:

• Billing Date: 1/15/2025
• Auth A: 20 hours already scheduled for 1/15
• Trying to add: Auth A for 6 more hours on 1/15
• Result: FAIL (would be 26 hours in one day)

Step 8: Validate Number of Visits (for Visit-Based Authorizations)

Rule: Number of visits used + visits being scheduled cannot exceed authorized visits for period

Example:

• Authorization: 5 visits per week
• Week: 1/12/2025 - 1/18/2025
• Already scheduled: 4 visits
• Available: 5 - 4 = 1 visit
• Trying to schedule: 1 visit
• Result: PASS

Step 9: Validate Number of Days Per Week

Rule: If authorization limits number of days per week, cannot exceed that limit

Applies when: Weekdays UOM = "Number" (e.g., "any 5 days per week")

Example:

• Authorization: 8 hours per day, any 5 days per week
• Week: 1/12/2025 - 1/18/2025
• Already scheduled: Mon, Tue, Wed, Thu, Fri
• Trying to schedule: Saturday
• Result: FAIL (would be 6 days, only 5 allowed)

Prerequisites

1. Contract Setting Must Be Enabled
   • Chart Contract must have "Allow Splitting Auths" = true
   • This is configured at the contract level
   • Different contracts for same patient can have different settings
2. Visit Must Be Overnight
   • Start date and end date must be different calendar days
   • Example: Start 1/15 11:00 PM, End 1/16 7:00 AM
3. Valid Authorizations for Each Date
   • Each billing date must have an active authorization
   • Each authorization must have sufficient units for its portion

Q: Can I split a single-day visit?

A: No. Split billing only works for overnight visits where the start and end dates are different calendar days. Single-day visits (even if they're 12+ hours) cannot be split.

Q: Can I split across more than 2 days?

A: The system supports billing dates for start and end dates. For multi-day visits (e.g., Friday 8 AM - Monday 8 AM), you would need to break this into separate visits or bill the entire duration to one authorization.

Q: Do the hours need to be split proportionally?

A: No. You can split hours however you need, as long as:

• Total hours match the visit duration
• Each authorization has sufficient units available
• No single billing date exceeds 24 hours

Example: 8-hour overnight visit can be split 7/1, 5/3, 4/4, etc. - whatever works for your authorization limits.

Q: What if I forget to enable "Allow Splitting Auths" on the contract?

A: The system will show a validation error when you try to use different billing dates. You'll need to either:

• Enable the setting on the chart contract, OR
• Use a single authorization for the entire visit billed to one date

1. Billable Units Requirement

Rule: Billing items are ONLY created when BillableUnitsOrHours > 0

Why: Zero-unit visits have nothing to bill

Implementation:

WHERE BillableUnitsOrHours > 0 AND BillingItemId IS NULL

Example Scenarios:

• Visit scheduled for 4 hours with authorization: ✓ Billing item created
• Visit scheduled for 0 hours (placeholder): ✗ No billing item
• Visit cancelled (units reduced to 0): ✗ Billing item removed or not created

2. Authorization Linkage

Rule: Authorization ID is stored on the BillingItemDetail table via ChartAuthorizationId

Why: Maintains linkage between billing and authorization for audit trail and rebilling

Data Flow:

1. User schedules visit and selects authorization(s)
2. Schedule saved with authorization ID(s) linked
3. Billing reconciliation creates BillingItem
4. BillingItemDetail created with ChartAuthorizationId from schedule
5. Authorization ID now traceable from bill back to original authorization

3. Split Authorization Tracking

Rule: Split authorizations are tracked via IsSplitAuth flag on billing items

Why: Identifies overnight visits billed across multiple dates for reporting and audit purposes

How It Works:

• When a visit has multiple billing dates (overnight split), the system sets IsSplitAuth = 1
• This flag helps identify which billing items are part of a split authorization scenario
• Reporting and analytics can filter or group by this flag

Example:

Visit: 1/15/2025 10 PM - 1/16/2025 6 AM (8 hours)
  → BillingItem 1: 5 hours, BillingDate = 1/15/2025, IsSplitAuth = 1
  → BillingItem 2: 3 hours, BillingDate = 1/16/2025, IsSplitAuth = 1

LHCSA Insurance Exclusion

Rule: LHCSA insurance contracts are excluded from standard billing reconciliation

Implementation:

WHERE ip.PlanName <> 'LHCSA'

Why: LHCSA (Licensed Home Care Services Agency) has specialized billing requirements and workflows that differ from standard home care billing

What This Means:

• LHCSA visits are handled by a separate billing process
• Standard authorization validation still applies to LHCSA schedules
• LHCSA billing items are created through a different pathway
• Users need special permission (CanAddEditAuthorizationsForLHCSAContract) to work with LHCSA authorizations

Efficient Processing

The billing reconciliation process is optimized for performance:

• Incremental Updates: Only processes schedules that have changed since last reconciliation
• Bulk Operations: Creates/updates multiple billing items in batches
• Index Optimization: Uses database indexes on BillingItemId, ChartAuthorizationId, and BillingDate
• Filtered Queries: Excludes LHCSA and zero-unit visits early in the query to reduce processing

1. Authorization Type Must Be "Regular"

Rule: System only auto-applies regular authorizations

Why: Accumulation authorizations require explicit user selection with proper permission

Exception: Users with "CanUseAccumulatedAuthUnits" permission can manually select accumulation authorizations

2. Authorization Must Be Active on Schedule Date

Rule: Start Date ≤ Schedule Date ≤ End Date

Example:

• Authorization: 1/1/2025 - 1/31/2025
• Schedule Date: 1/15/2025 ✓ Eligible
• Schedule Date: 2/5/2025 ✗ Not Eligible

3. Chart Contract Must Be Active

Rule: Contract Effective Date ≤ Schedule Date, and (Contract End Date is null OR ≥ Schedule Date)

Why: Even if authorization is active, the patient's insurance contract must also be active

4. Service Code Must Match

Rule: Authorization detail must exist for the same service code as the scheduled visit

Example:

• Visit Service Code: Skilled Nursing (RN)
• Authorization must have a detail for Skilled Nursing (RN)
• Authorization with only Physical Therapy will not be selected

5. LHCSA and Charity Insurances Excluded

Rule: LHCSA and Charity insurance contracts are excluded from auto-apply

Why: These require special handling and explicit user selection

Permission: Users need "CanAddEditAuthorizationsForLHCSAContract" or "CanAddEditAuthorizationsForCharityContract" to use these

6. Primary Contract Preferred

Rule: If multiple authorizations meet all criteria, select from primary contract

Why: Patients often have multiple insurances; primary insurance should be billed first

Example:

• Patient has Medicare (Primary) and Medicaid (Secondary)
• Both have active authorizations for same service
• System selects Medicare authorization

7. If Only One Option, Select It

Rule: If only one authorization meets all criteria, use it regardless of primary status

Why: Simplifies scheduling when choice is obvious

Weekly Authorization Units

Method: Get day-specific units or total weekly units

Day-Specific Units:

• If authorization specifies SunUnits, MonUnits, etc., use those values
• Example: Authorization has MonUnits=4, TueUnits=4, WedUnits=2
• Monday visit: 4 hours available
• Wednesday visit: 2 hours available
• If day has 0 units: Cannot schedule on that day

Number of Days:

• If Weekdays UOM = Number (e.g., "any 5 days")
• Any day returns full weekly units
• Example: 40 hours per week, any 5 days = 40 hours available per day
• System validates number of days separately

Daily Authorization Units

Method: Return per-day units, check if day is allowed

Specific Days:

• If Weekdays UOM = Day with specific days selected
• Check if schedule day is in selected days
• If yes: Return daily units
• If no: Return error (day not allowed)

Number of Days:

• If Weekdays UOM = Number
• Return daily units for any day
• System validates total days per week separately

Allowed to Vary:

• If "Weekdays Allowed to Vary" = true
• Return daily units for any day regardless of selection

Monthly Authorization Units

Method: Return full monthly units

Period: First day of month to last day of month

Example:

• Authorization: 160 hours per month
• Any day in January: 160 hours available (minus already used)

Period Authorization Units

Method: Return full authorization units

Period: Authorization start date to end date

Example:

• Authorization: 100 hours total, 1/1/2025 - 3/31/2025
• Any day within range: 100 hours available (minus already used)

Issue: Authorization Not Appearing in Selection List

Possible Causes:

• Authorization dates don't include the schedule date
• Service code doesn't match between authorization and visit
• Chart contract is not active
• Authorization is accumulation type and user lacks permission
• Authorization is LHCSA/Charity and user lacks permission
• Day of week not allowed by authorization

How to Fix:

1. Verify authorization start/end dates include schedule date
2. Check authorization has detail for the correct service code
3. Confirm chart contract is active on schedule date
4. Request "CanUseAccumulatedAuthUnits" permission if needed
5. Check weekday configuration allows the schedule day

Issue: "Authorization cannot be linked more than once to a schedule"

Cause: Same authorization linked multiple times with same billing date

How to Fix:

1. Review authorizations on the visit
2. Remove duplicate authorization entries
3. If splitting hours, ensure each entry has different billing date OR different authorization

Issue: "Authorization [number] cannot be used for a split billing"

Cause: Trying to use different billing dates but contract doesn't allow split billing

How to Fix:

1. Go to Chart Contract settings
2. Enable "Allow Splitting Auths" setting
3. OR use single authorization with single billing date

Issue: "Authorization [number] will exceed the maximum [X] units allowed"

Cause: Authorization has MaxUnitsForAuthorization cap that would be exceeded

How to Fix:

1. Review total units used on authorization detail
2. Check if MaxUnitsForAuthorization needs to be increased
3. Consider using different authorization or splitting visit
4. Verify if some visits were incorrectly billed to this authorization

Issue: "Authorization [number] is not authorized for [day of week]"

Cause: Schedule date falls on a day not allowed by authorization's weekday configuration

How to Fix:

1. Check authorization's weekday settings
2. Verify Weekdays UOM (Day or Number) and Weekdays Value
3. If day should be allowed, update authorization weekday configuration
4. If day should not be allowed, reschedule visit to allowed day
5. Check if "Weekdays Allowed to Vary" should be enabled

Issue: "Authorization [number] does not have enough available hours/visits"

Cause: Insufficient units available for the period

How to Fix:

1. Check authorization period type and units
2. Review usage report for the period to see what's already scheduled/confirmed
3. Consider using accumulation authorization if available
4. For overnight visits, consider split billing across two periods
5. Verify if some visits need to be rescheduled or removed
6. Check if authorization needs to be increased

Issue: "Authorization [number] usage would exceed 24 hours in a single day"

Cause: Single billing date would have more than 24 hours (impossible)

How to Fix:

1. Review all visits scheduled for that billing date
2. Check if visit durations are correct (not accidentally 20 hours instead of 2 hours)
3. Verify billing dates are set correctly
4. For overnight visits, ensure proper split billing configuration

Issue: "Authorization [number] allows a maximum of [X] days per week"

Cause: Authorization has "Number of Days" constraint (e.g., "any 5 days per week")

How to Fix:

1. Review which days are already scheduled in the week
2. Reschedule visit to a week with available days
3. Check if authorization needs to be changed to allow more days
4. Consider if some existing visits need to be moved

Issue: System Auto-Selected Wrong Authorization

Cause: Multiple authorizations available; system selected based on priority rules

How to Fix:

1. Manually change to the correct authorization
2. If this happens frequently, review contract "Is Primary" settings
3. Consider if authorizations need different date ranges to avoid overlap

Issue: Cannot See Accumulation Authorization

Cause: User lacks "CanUseAccumulatedAuthUnits" permission

How to Fix:

1. Request permission from system administrator
2. Verify accumulation authorization exists (check authorization list)
3. Confirm insurance has "Allow Accumulating Auth" enabled