Eligibility is assessed, not just enrolled
ALTCS eligibility involves both financial and functional or medical assessment, and members are assigned to a programme contractor that administers their care. Eligibility can change during a long episode of care, and a change that nobody in your billing process notices will produce a run of denials rather than a single one.
Treat eligibility as a monitored status for the duration of the stay or service period, not a box ticked at admission.
Case management sits between you and payment
ALTCS care is delivered against an authorised plan of care coordinated by the member's case manager. Services delivered outside what is authorised — more hours than approved, a different service, a changed setting — are frequently unpayable regardless of clinical justification.
So the billing control is upstream: the authorised services, units and period must be visible to whoever schedules and documents care, and any change must go through the case manager before delivery, not after.
Share of cost and coordination of benefits
Some ALTCS members have a share of cost, and many are dual-eligible with Medicare or hold other coverage. That makes correct payer ordering, accurate posting of the member responsibility portion, and timely secondary billing central to whether the account ever closes cleanly.
The amounts, thresholds and ordering rules are programme rules, not ours to publish — confirm them with AHCCCS and with the member's contractor. What we can say operationally is that unposted share of cost and delayed secondary claims are the two largest sources of phantom A/R in long-term care billing.
Documentation over long service periods
Long stays generate far more documentation risk than episodic care: daily or per-visit records, staffing and credential evidence, changes in condition, leave days and transfers. Each of those can affect what is billable for a given period.
Build the reconciliation between authorised units, documented delivery and billed units into the monthly close, rather than trusting that three systems agree. Where they diverge, it is almost always the same small number of service types.
How NEXACC handles it
We reconcile authorisation, documentation and billing for each service period, coordinate with case management on changes before they are delivered, post share of cost correctly, and drive secondary billing on a schedule instead of on discovery. Reporting shows collections against authorised care, which is the only view that tells a long-term care operator whether the month actually worked.