Units and Billing Rules

Understanding Service Units

A service unit is the measurement used to record and calculate the amount of service delivered.

Depending on the service, a unit may represent:

• 15 minutes.
• One hour.
• One day.
• One mile.
• One trip.
• One completed event.
• Another payer-approved measurement.

The selected unit must match the Service Code, Service Rate, authorization, visit documentation, and payer billing rules.

Provider-Specific Billing Rules

Billing rules may differ between Providers and services. A rule used by one Provider should not automatically be applied to another Provider.

Differences may result from:

• Different payers.
• Different programs or waivers.
• Different Service Codes.
• Different authorization structures.
• Different unit formats.
• Different rounding rules.
• Different minimum or maximum service durations.
• Different EVV requirements.
• Different documentation requirements.
• Different billing effective dates.

Supported Unit Formats

15-Minute Unit Conversion

For a service configured as Unit (15 min), service time is divided into 15-minute increments.

The mathematical conversion does not by itself determine the final billable units. Payer rounding rules, authorization limits, documentation, EVV validation, and other billing controls may also apply.

Unit Conversion Examples

Partial Units

A visit may contain service time that does not divide evenly into complete units.

Examples include:

• 22 minutes.
• 38 minutes.
• 53 minutes.
• 68 minutes.

The Provider must apply the payer's approved partial-unit or rounding rule.

Rounding Rules

Rounding determines how incomplete units are handled.

Possible payer-defined approaches may include:

• Round down to completed units.
• Round to the nearest unit.
• Use a minimum-minute threshold.
• Use a midpoint rule.
• Allow partial decimal units.
• Disallow incomplete units.
• Apply a daily aggregate rule.

The actual method must be based on the payer, program, code, and official billing requirements.

Example Rounding Scenarios

The following scenarios are conceptual examples only. They are not universal billing rules.

Hourly Billing

For hourly services, the duration is calculated using hours rather than 15-minute units.

The final amount may depend on approved rounding, partial-hour, minimum-duration, or maximum-duration rules.

Daily Billing

A daily service is generally measured as one approved service day rather than by individual minutes or hours.

Daily billing may require validation of:

• The individual was eligible on the service date.
• The service was authorized for a daily unit.
• The required minimum service conditions were met.
• Required daily documentation was completed.
• The service was not billed more than once when duplication is prohibited.
• The daily service does not conflict with another service.

Mileage Billing

Mileage billing uses the number of approved miles as the unit.

Mileage billing may require:

• Beginning and ending location.
• Approved transportation purpose.
• Recorded mileage.
• Individual participation.
• Transportation documentation.
• Authorization for mileage.
• Applicable zone or trip rules.

Trip-Based Billing

A trip-based service is billed for each approved completed trip.

Trip billing may depend on:

• Origin and destination.
• Trip completion.
• Individual eligibility.
• Authorization.
• Approved Service Code.
• Trip type.
• Zone.
• Required supporting documentation.

A canceled or incomplete trip should not automatically be treated as a completed billable trip.

Event-Based Billing

Event-based billing applies when one completed activity or occurrence represents one billable unit.

The Provider should define:

• What qualifies as a completed event.
• Required documentation.
• Maximum events per day or period.
• Authorization requirements.
• Whether duplicate events are allowed.
• The effective rate per event.

Billable and Non-Billable Services

The Service is billable setting determines whether the service is intended for billing-related workflows.

Authorization Limits

Billing units should not exceed the units approved by the individual's authorization.

Authorization controls may include:

• Total approved units.
• Remaining units.
• Units per day.
• Units per week.
• Units per month.
• Units per authorization period.
• Approved Service Code.
• Approved service level.
• Effective start and end dates.

Service Dates

A visit must occur within the valid service and authorization period.

Review:

• Service effective date.
• Service end date.
• Authorization start date.
• Authorization end date.
• Rate effective date.
• Service Code effective date.
• Visit date.

A correct service delivered outside an authorized period may not be billable.

Visit Time Validation

Time-based billing normally requires valid service start and end times.

Review may include:

• Check-in is present.
• Check-out is present.
• Check-out occurs after check-in.
• Duration is reasonable.
• Visit does not overlap an incompatible visit.
• Time corrections include a required reason.
• Visit status is complete.
• Employee and individual match the scheduled service.

EVV Requirements

Services subject to Electronic Visit Verification may require additional data before they are billing-ready.

EVV data may include:

• Individual identifier.
• Employee identifier.
• Service Code.
• Check-in date and time.
• Check-out date and time.
• Visit location.
• GPS coordinates.
• Call type or mobile method.
• Provider identification.
• Payer and program.

An incorrect Service Code, missing call, invalid time, or missing identifier may cause the visit to fail validation or submission.

Billing Readiness

A service visit should be considered ready for billing only after required validation is complete.

Billing Calculation Example

The following example demonstrates a basic unit-and-rate calculation.

Before billing, the Provider must still confirm:

• Authorization has at least 6 available units.
• The visit is within authorized dates.
• The Service Code is correct.
• The rate is effective.
• The visit is complete.
• EVV requirements are satisfied.
• Documentation is complete.
• No payer rule reduces or excludes the calculated units.

Minimum and Maximum Rules

Some services may have minimum or maximum limits.

Examples include:

• Minimum duration for one billable unit.
• Maximum units per visit.
• Maximum units per day.
• Maximum units per week.
• Maximum units per authorization period.
• Maximum daily mileage.
• Maximum number of trips.
• Maximum number of events.

These limits should be configured or reviewed according to the Provider's approved source.

Duplicate Billing Prevention

Billing controls should prevent the same service activity from being billed more than once.

Duplicate review may include:

• Same individual.
• Same employee.
• Same Service Code.
• Same date.
• Same check-in and check-out.
• Overlapping service times.
• Same trip or event.
• Visit already included in another claim batch.
• Visit already submitted or paid.

Overlapping Services

Overlapping visits may require review when one individual or one employee appears in multiple service records during the same time.

An overlap does not automatically mean an error in every case, but the Provider should confirm:

• Whether simultaneous services are allowed.
• Whether group-service rules apply.
• Whether the same employee can deliver both services.
• Whether one record is a duplicate.
• Whether time was entered incorrectly.
• Whether the payer permits concurrent billing.

Canceled and Incomplete Visits

A canceled or incomplete visit should not automatically produce billable units.

Review:

• Visit status.
• Cancellation reason.
• Check-in and check-out.
• Service documentation.
• Payer cancellation policy.
• Whether a minimum service was delivered.
• Whether the service is eligible for any approved exception.

Manual Time Corrections

Authorized users may need to correct visit times when valid service information was not captured correctly.

A correction workflow should require:

• Original time.
• Corrected time.
• Reason for correction.
• User making the correction.
• Date and time of correction.
• Review of recalculated units.
• Review of authorization impact.
• Audit logging.

Unit and Billing Configuration Checklist

Review the following before activating a service:

• The Provider is authorized to deliver the service.
• The Service Name is correct.
• The Service Code is correct.
• The payer and program are correct.
• The unit format is correct.
• The rate is correct.
• The ratio or zone is correct.
• The rounding rule has been verified.
• Minimum and maximum limits have been reviewed.
• Authorization rules have been reviewed.
• EVV requirements have been reviewed.
• Documentation requirements have been reviewed.
• The billable setting is correct.
• Effective dates are correct.

Updating Unit or Billing Rules

Unit and billing-rule changes should be handled carefully because existing services may already be used by authorizations, schedules, visits, billing records, and claims.

Before making a change:

1. Confirm the official source of the change.
2. Confirm the effective date.
3. Review existing authorizations.
4. Review scheduled visits.
5. Review completed visits.
6. Review unsubmitted billing records.
7. Review submitted claims.
8. Determine whether historical records must retain the old rule.
9. Determine whether a new service record is required.
10. Document the reason for the change.

When to Create a New Service Configuration

A separate service configuration may be safer when:

• The unit format changes.
• The Service Code changes.
• The rate changes with a new effective period.
• The ratio or zone changes.
• The rounding rule changes.
• The payer changes.
• The program or waiver changes.
• The service becomes subject to different EVV rules.
• Historical visits must retain the previous configuration.

Common Unit and Billing Errors

Best Practices

• Verify the unit format from an approved source.
• Verify the payer's rounding rule.
• Confirm authorization units before billing.
• Review effective dates.
• Verify Service Code and rate alignment.
• Review EVV requirements.
• Require reasons for manual time corrections.
• Prevent duplicate billing.
• Review overlapping visits.
• Preserve historical configurations.
• Do not copy rules from another Provider without verification.
• Restrict billing-rule changes to authorized personnel.

Security

• Only authorized users should create or modify units and billing rules.
• Billing configuration access should follow assigned job responsibilities.
• Changes to units, rates, codes, and rounding rules should be reviewed by authorized personnel.
• Manual visit corrections should be recorded in Audit Logs.
• Unauthorized changes may affect claims, reimbursement, reporting, and compliance.

HIPAA Considerations

• Unit and billing configuration should not contain unnecessary individual Protected Health Information.
• Access to visits, authorizations, billing records, and service details should follow the minimum necessary principle.
• Do not include individual names or diagnoses in general billing rule fields.
• Protect service and billing records from unauthorized access or modification.
• Maintain accurate audit history for corrections affecting PHI, service units, and billing.

Troubleshooting

The calculated units are incorrect.

• Verify check-in and check-out times.
• Verify the selected unit format.
• Review the rounding rule.
• Confirm whether decimal units are allowed.
• Check for manual time corrections.
• Confirm the visit duration.

The visit exceeds authorization units.

• Review the total authorized units.
• Review previously used units.
• Confirm the visit uses the correct service.
• Verify that duplicate visits do not exist.
• Contact authorized staff before billing excess units.

The visit does not appear as billing-ready.

• Confirm the service is billable.
• Confirm the service is Active.
• Verify check-in and check-out.
• Verify authorization dates and units.
• Verify Service Code and rate.
• Verify EVV data.
• Verify required documentation.

The billed amount is too high or too low.

• Verify calculated units.
• Verify the configured rate.
• Confirm whether the rate is hourly or per 15-minute unit.
• Review rounding rules.
• Confirm the correct ratio or zone.
• Confirm the correct effective date.

A duplicate service appears in billing.

• Review Visit Maintenance.
• Compare check-in and check-out times.
• Review the individual and employee.
• Review the Service Code.
• Confirm whether both records represent valid separate visits.
• Remove or correct the duplicate before submission.

Frequently Asked Questions

How many 15-minute units are in one hour?

Four 15-minute units equal one hour.

Does every payer use the same rounding rule?

No. Rounding rules may differ by payer, program, service, code, or unit format.

Can incomplete units be billed?

Only when the applicable payer or program rules permit partial, rounded, or decimal units.

Does Billable = Yes mean the visit can be billed immediately?

No. The visit must also satisfy authorization, EVV, documentation, time, unit, rate, code, payer, and other validation requirements.

Can a visit exceed the authorized units?

The system may identify the variance, but the excess units should not be billed without appropriate authorization or approved correction.

Can one service use different unit formats?

Yes, when the Provider's approved configuration requires separate service levels or records. Separate service configurations may be appropriate to preserve clarity and history.

Is a daily service calculated from check-in and check-out?

Not necessarily. A daily service follows the payer's approved daily billing requirements, although service documentation or visit times may still be required.

Should old billing rules be deleted?

Normally, no. Preserve historical rules and use effective dates, inactivation, or a new service configuration.

What happens when a check-out time is corrected?

The service duration, units, authorization use, billing amount, EVV status, and billing readiness may all be recalculated.

Related Documentation

• Service Management Overview
• New Service
• Search Services
• Service Details
• Service Codes
• Service Rates
• Service Status