When Visits are funded by a Electronic Billing-type Funder, the billing process in AlayaCare follows different steps. This article provides an overview of the Electronic Billing process:
- Creating Electronic Billing-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
- Adding Transactions to Claims
- Revising and Resending Claims
- Voiding Claims
- Accounting for Clawbacks
To use Electronic Billing, the Electronic Billing Integration Feature Flag must be turned on in Settings>All Settings>Features.
Creating Electronic Billing-type Funders and Bill Codes
To generate claims for Electronic Billing, you must first create Bill Codes with Electronic Billing-type Funders.
When you select Electronic Billing 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 Electronic Billing-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 an Electronic Billing-type Funder.
Viewing Funders' Claims in the Electronic Billing Summary
The Electronic Billing Summary (Accounting>Billing>Electronic Billing Summary) page lists all Electronic Billing-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 must 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 cannot 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 for the Funder 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 View on the Funder from the Electronic Billing Summary page and then choose the claim you wish to view. From here, you can see a breakdown of the Visits included in the claim and the Claim History.
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.
In the Claim Breakdown section, all Visits included on the claim will be listed with their Visit ID, Start Time, End Time, Service Code, and Quantity of units (based on the approved Visit time).
The Bank Adjustment field will be populated with the number of Billing Increments from the Bank used to round the Quantity up or down to the nearest whole unit. The Calculated Total field will display the total number of Billing Increments (in whole units) to be billed on the claim.
Any Unapproved Visits that are included will be marked with an orange warning icon.
In the Claim History section, you will see a history of changes (such as changes in status) 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 the 837 that prevents the claim from moving forward in the billing process.
A claim must be Marked for 837 Preparation before it can be prepared. Click View on the claim you wish to prepare and then click Mark for 837 Preparation.
You can also click the arrow next to View in the Funder's claims list and select Mark for 837 Preparation.
Next, click Prepare Claims to prepare all claims Marked for 837 Preparation.
You can also click the arrow next to View for the Funder in the Electronic Billing Summary and select Prepare Claims.
Once claims have been Prepared, they can be sent to the clearinghouse in a 837 EDI file. To send claims, click Send 837 from the Funder's claims list.
Alternatively, click the arrow next to View for the Funder in the Electronic Billing Summary and select Send 837.
Posting to the Subledger for Claims
When a claim is sent, a Sale transaction is posted to the subledger for the value of the claim. This transaction will be added to the Claim Transactions list on the claim details page.
If a Bank Adjustment is made, a Credit Note or Debit Note will be made to represent the adjustment. If the claim increases in value because time from the Bank 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.
Manually Changing a Claim's Status
In some cases, a Funder may choose to respond to a claim directly to your organization instead of through the clearinghouse. In these instances, AlayaCare will not receive the 835 file and thus cannot automatically update the claim's status to Paid or Denied.
If you wish to ensure that the claim record in AlayaCare accurately reflects the status of a claim, you can manually change the status of an Accepted claim to either Paid or Denied or the status of a Denied claim to Paid.
To do so, click the icon next to Accepted.
In the dialogue box, you will see the following warning: You should only manually update the status of a claim if you know you will not receive an 835 file for this claim.
To proceed, select either Paid or Denied as the New Status and enter the Internal Control Number (the adjudication number). You also have the option to check Allow Internal Control Number to Remain Empty.
If you select Paid as the New Status, a new Transaction Details section will open below with Payment selected and locked as the Transaction Type. The Amount field will be populated with the claim amount but can be edited as necessary. You can also change the Posting Date from today's date.
If you select Denied as the New Status, the Transaction Details section will appear with Writeoff selected and locked as the Transaction Type. The Amount field will be populated with the claim amount but can be edited if necessary. Note, however, that you cannot write off more than the amount of the claim. Select an Expense Account and adjust the Posting Date as necessary.
Opening and Closing Claims
Claims with a status of Draft or Prepared are considered Open, which means the Visits on the claim can be edited. Claims with a status of Acknowledged or Accepted are Closed and locked for editing as they are still being processed. Claims that have a status of Rejected, Denied, or Paid are Closed but can be reopened by a user configured with the ACL Open/Close Claims.
Only an open claim can be prepared, sent, 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 .
Adding Transactions to Claims
Once you reopen a claim that has been Rejected, Paid, or Denied, you will also have the option to add transactions to the claim to readjust the value.
To add a transaction to a claim, click the +Add Transaction button from the claim details page.
In the dialogue box, select the type of transaction you wish to add to the claim.
If the claim has a status of Rejected, you can select Writeoff as the Transaction Type. This will allow you to write off up to the balance of the claim.
If the claim has a status of Paid or Denied, you can select Payment (for up to the total amount of the claim), Credit Note (for up to the balance of the claim), Debit Note (for any amount), or Writeoff (for up to the balance of the claim).
Adjust the Amount of the transaction and Posting Date as necessary. If Writeoff is selected as the Transaction Type, you must also select an Expense Account. When you have finished, click Add Transaction.
If you wish to reverse a Payment transaction on an open claim, you can do so directly from the Claim Transactions list. Click the arrow next to Allocate or Allocations and select Reverse.
In the dialogue box, Cancel Cash Receipt will be selected as the Transaction Type along with the Electronic Billing-type Funder for this claim and the claim Amount. These fields will be locked for editing. Adjust the Posting Date and enter a Comment if necessary. When you have finished, click Save.
A new transaction of Type Cancel Cash Receipt will be added to the Claim Transactions list.
Revising and Resending Claims
If you need to make changes to a claim that has already been Paid or Denied, you can revise the claim and resend it to the Funder directly from AlayaCare. If you have already resent the claim from the clearinghouse, you can also revise the claim in AlayaCare so that it matches the record in the clearinghouse.
To begin, click the Revise button from the claim details screen.
If you have already resent the claim from the clearinghouse, select Revise claim to reconcile with clearinghouse. Make any necessary adjustments to the Procedure Code, Procedure Modifier, or Quantity and then click Revise and Reconcile.
If you wish to update the claim and then send it to the Funder via the clearinghouse from AlayaCare, select Revise claim in AlayaCare and resend to clearinghouse. Adjust the Bill Code as necessary and then click Revise and Resend.
You may receive an error message if you change the Bill Code so that the claim conflicts with another existing claim. For more details, see How do I revise and resend Electronic Billing claims?
The status of the claim will change to Revised. If you are revising the claim to reconcile it with the clearinghouse, the icon will appear in the status. If you are revising the claim to resend from AlayaCare, the icon will appear in the status.
If you are resending the claim from AlayaCare, the Revised claim will be ready to be prepared. The next time you select Prepare Claims for the Funder it will be prepared along with any other Draft claims. After preparing the claim, you can then select Send 837 to resend the revised claim to the Funder via the clearinghouse.
Claims with a status of Draft, Prepared, Rejected, Paid, or Denied can be marked as Void and resubmitted to the Funder via the clearinghouse if necessary. If you have already voided a claim in the clearinghouse, you can mark the claim as void in AlayaCare so that it matches the record in the clearinghouse.
To void a claim, select the Void button from the claim details screen.
When voiding a Draft or Prepared claim, you will only be able to select Void claim in AlayaCare and resend to clearinghouse as the claim has not yet been sent.
If you have already voided a Rejected, Paid, or Denied claim in the clearinghouse, select Void claim to reconcile with clearinghouse. This will allow you to change the status of the claim to Void in AlayaCare and reverse any transactions (except payments) associated with the claim (the Sale transaction created when the claim was sent along with any credits and debits against the Bank).
If you need to void the claim and resend it from AlayaCare, select Void claim in AlayaCare and resend to clearinghouse. In addition to changing the status to Void and reversing all transactions on the claim except payments, this action will also prepare the claim to be resent to the Funder through the clearinghouse.
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) by reversing the credit and debit.
To see whether a claim includes Clawbacks, click the icon and turn on Clawback.
A tooltip will appear in the Status column for claims that have a Clawback.