When Visits are funded by a Medicaid-type Funder, the billing process in AlayaCare follows different steps. This article provides an overview of the Electronic Billing process:
- Creating Medicaid-type Funders and Bill Codes
- Understanding the Claim Bank
- Viewing Funders' Claims in the Electronic Billing Summary
- Generating Claims
- Viewing Claim Details
- Preparing Claims
- Sending Claims
- Opening and Closing Claims
- Posting to the Subledger for Claims
- Making Adjustments and Resubmitting Claims
- Accounting for Clawbacks
To use Electronic Billing, the Electronic Billing Integration Feature Flag must be turned on in Settings>All Settings>Features.
Creating Medicaid-type Funders and Bill Codes
To generate claims for Electronic Billing, you must first create Bill Codes with Medicaid-type Funders.
When you select Medicaid as the Funder Type, you are required to supply some additional information, including the Payer Code, Payer Name, and Payer Electronic Transmitter Identifier (ETIN) and your Provider Code, Provider Name, and Provider Electronic Transmitter Identifier (ETIN). You have the option to include your Provider Tax ID and Provider Taxonomy Code.
Check the Use Bank option if you want claims to use and contribute to Banked Time for each Bill Code/Client. If Use Bank is unchecked, claims will be rounded down for billing. For more about the Time Bank, see below.
When creating a Bill Code with a Medicaid-type Funder, you must specify the following:
- Billing Increment: the amount of time that constitutes a billable unit when generating claims from the Bill Code. The possible options are 60 minutes, 30 minutes, or 15 minutes.
- Location Indicator: a code that indicates where a Service occurred (the Client's home, a clinic, etc.). You can select available options from the dropdown menu.
Understanding the Time Bank
Claims are billed in terms of units of time, which are set as the Billing Increment at the Bill Code level. Claims can only be billed in terms of complete units and are always rounded down to the nearest whole unit. This means that if a Visit lasts 1.5 hours and the Billing Increment is 60 minutes, the agency has to submit a claim with a value of only 1 hour and thus loses the extra half hour of service it provided.
Some Funders allow providers to "bank" the extra service time and use it to top off other claims. This way claims still respect the Billing Increment, but agencies can bill for the entirety of the service provided. This means that if a Visit lasts for 1.5 hours and the Billing Increment is 60 minutes, the agency can reserve the extra half hour in the bank and use it toward another claim with a Visit lasting 1.5 hours. They can then submit a second claim for 2 hours instead of 1. These banked hours can only be used toward future claims where the following conditions are met:
- The claims have the same Payor.
- The claims have the same Bill/Procedure Code.
- The claims are for the same Client.
Agencies should indicate whether they wish to use Banked Time for claims by checking the Use Bank option when creating a Medicaid-type Funder.
Viewing Funders' Claims in the Electronic Billing Summary
The Electronic Billing Summary (Accounting>Billing>Electronic Billing Summary) page lists all Medicaid-type Funders and the status of all claims within a given date range. The date range filter at the top of the page is by default set to the last 60 days.
Funding for Electronic Billing is paid out on behalf of recipients through insurance companies that ensure that the correct Services have been rendered. Claims are submitted to these Funders through a third-party clearinghouse. The clearinghouse is responsible for ensuring that the claims are sent to the right Funders and for collecting the Funders' responses, which are then sent back to AlayaCare.
There are eight possible statuses for claims:
- Draft: the claim has been generated but not prepared or sent. A claim can't change in status from Draft to Prepared until all Visits included in the claim have been approved.
- Prepared: the claim has been generated and is ready to send.
- Sent: a 837 EDI file has been submitted for the claim to the clearinghouse.
- Acknowledged: a 999 EDI has been received for the claim by the clearinghouse.
- Accepted: a 277 EDI has been received for the claim and approved to be sent on to the Funder.
- Rejected: a 277 EDI has been received for the claim, but it will not be sent to the Funder due to an error.
- Paid: an 835 EDI has been received for the claim along with a payment from the Funder.
- Denied: an 835 EDI has been received for the claim and payment has been refused.
Click View on a Funder in the Electronic Billing Summary to view all claims for that Funder.
To generate new claims, click View on a Funder from the Electronic Billing Summary page.
Next, click Generate Claims. This will launch a background job to create new claims for recent Visits.
Alternatively, you can complete this step by clicking the arrow next to View and select Generate Claims.
Note that only Visits that have the same Bill Code, Client ID, and Visit Start Date will be included on the same claim.
At least one Visit must be approved for a claim to be created. If Unapproved Visits are included on the claim, a warning icon will appear next to the claim's status in the Funder's list of claims. As long as a claim contains at least one Unapproved Visit, it cannot be Prepared.
Viewing Claim Details
To view the details of a claim, click on the Funder from the Electronic Billing Summary page and then choose the claim you wish to view. From here, you can see a summary of the claim information, a breakdown of the Visits included in the claim and the Claim History. Any Unapproved Visits that are included will be marked with a warning icon.
In the Summary section, you will see the Client Name, Service Date, Bill Code, Procedure Code, Procedure Modifier(s), Delay Code, Denial Reason (when/if applicable), Internal Control #, and any Comments. The Internal Control # will be populated only after the claim has been adjudicated.
You can add a Delay Code from here if necessary. Click the icon and select the correct Delay Code from the dropdown. Then, click the icon to add the Delay Code to the claim.
To add a Comment, Click the icon, enter your comments, and then click the icon to save.
The Claim Breakdown section will list all Visits included on the claim along with the Visit ID, Start Time, End Time, Service Code, and Quantity of Billing Increments.
The Claim History will list changes that have been made to the claim listed by the date and time that the change occurred. Other information listed includes the Status, Quantity, Bill Code, Procedure Code, Procedure Modifier(s), Internal Control #, Delay Code, and 837 Issues. The 837 Issues column will be left blank unless an error occurs when sending an 837 that prevents the claim from moving forward through the billing process.
A claim must be Marked for Submission before it can be prepared. Click View on the claim you wish to prepare and then click Mark for Submission.
You can also click the arrow next to View in the Funder's claims list and select Mark for Submission.
Next, click Prepare Claims to prepare all claims Marked for Submission.
You can also click the arrow next to View for the Funder in the Electronic Billing Summary and select Prepare Claims.
You will be asked to confirm whether you wish to prepare claims to submit to the Funder.
Click Prepare Claims to continue.
Once claims have been Prepared, they can be sent to the clearinghouse as 837 EDI files. To send claims, click Send 837 from the Funder's claims list.
Alternatively, click the arrow next to View for the Funder in the Medicaid Summary and select Send 837.
In the dialogue box, click Send 837 to confirm.
Once the claim has been received by the clearinghouse, the status will change from Sent to Acknowledged.
Opening and Closing Claims
A claim that has a status of Rejected, Denied, or Paid can be reopened by a user configured with the ACL Open/Close Claims. When a claim is opened, the Visits in the claim can be edited. When the claim is closed, the Visits in the claim cannot be edited.
Only an open claim can be prepared, marked for submission, or edited. The icon next to the status in the claims list indicates that a claim is closed. To open it, click on the claim and then click
Posting to the Subledger for Claims
When a claim is submitted, a Sale transaction is posted to the subledger for the value of the claim.
If an adjustment is made to account for Banked Time, a Credit Note or Debit Note will be made to represent the adjustment. If the claim increases in value because Banked Time was used, a Debit Note will be created. If the claim decreases in value with rounding and time is added to the Bank, a Credit Note will be created.
Making Adjustments and Resubmitting Claims
Claims that have been Rejected, Denied, or Paid can be reopened and edited. To make an adjustment to a claim, click Open. The option to Make Adjustment will then become available.
Click Make Adjustment. Then select the Transaction Type, enter the amount, and choose the Posting Date. Click Make Adjustment to update the claim.
After making the adjustment, click Mark for Submission. You can now prepare the claim again and then resend it to the Funder.
Accounting for Clawbacks
Medicaid 835 EDI files can contain a negative value adjudication line item on a claim that has already been paid. When an 835 file with a negative adjudication is received, a type of transaction called a Partial Payment Return, or Clawback, will be created in the system.
To account for the payment refund, the transaction will reduce the payment using the accounts associated with the claim (the GL Bank and Receivables configured at the Funder level) but reversing the credit and debit.
To see whether a claim includes Clawbacks, click the icon and turn on Clawback.