What is a Special 485?
A "Special 485" is a 485 that gets created when there is a payer source change from one PPS payer to another PPS payer, during an episodic period. The Special 485 is only created for billing purposes. This allows the creation of the correctly dated episode for the "changed to payer." ( ***If you are changing from a PPS payer to Medicare, it is best to discharge and readmit the patient.)
Example: Patient X admitted on 11/23/22 under Medicare: Episode date-11/23/22-12/22/22
Payer source changed to Humana on 12/01/22; however, the first billable visit was not made until 12/05/22
In this case, you would need to generate an NOA for Humana with 12/05/22 as the episodic start date
Once the Special 485 is created, it will be marked as Mailed and Received as of the date you created it. After the Special 485 is created, you will then be able to create the NOA for the episodic period. These are the steps in how to create the Special 485:
First, make the appropriate changes in the Referral > Payers tab
a. Select the payer that is no longer primary
b. Put in the discharged date for that payer
c. Select the next available slot to put in the primary payer information
d. Type in the Program, Payer#, HIC#
e. Select Move to Primary tab
f. Select the primary payer you just created
g. At Medicare Advantage Plan Enroll Date, type in the date of the first billable visit (This ensures the NOA date is created correctly)
h. Click the Save Payer tab
Next, change the visits accordingly to the primary payer
Click here for instructions on how to change visit info.
Next, you will create the Special 485
a. Select the Patient on the Select Patient screen
b. Click the New 485 tab
c. Type in the From date, which would be the date of the first billable visit
d. Mark the checkbox for "This is a Special 485 for MA Plan Billing Only"
e. Type in the appropriate Doctor and Employee
f. Click Create a New 485 tab
g. Click Save
The Special 485 will have an (*) in the MA column; Box 21 will show "Special 485 for Medicare Advantage Plan Billing" and can only contain that phrase. The 485 is marked as mailed and returned, so it will not show up to be mailed.
Finally, you will create the PPS Episode. This will allow the creation of the NOA.
a. Select the Special 485 from the 485 screen
b. Click the Create PPS Episode tab
c. You will receive a popup "Both 30 day episodes created." Note: If the patient is discharged prior to the start of the 2nd episode, the 2nd episode will be removed.
The NOA will now generate for billing.
NOTE: If the payer is changed late, and episodes are created under the wrong payer source, you may also need delete those episodes created in error. This can be done under Billing >PPS Billing > Edit PPS Episodes. Select the episode(s) that needs to be removed, click Delete this Episode tab. Click Yes to delete. If the NOA or EOE has already been created, you will need to cancel those first, in order for the Delete this Episode button to be active.