In Electronic Billing in AlayaCare, you can create and send both Professional and Institutional Claims to Funders via the clearinghouse.
Before you can generate Institutional Claims, you must select Institutional as the Claim Type when creating a Electronic Billing-type Funder and complete the required fields specific to Institutional Claims on the Bill Code.
Note: Institutional Claims contain a field for the name of the Attending Physician. To set an Attending Physician for a Client, create a Client Contact and enter Attending Physician as the Relationship. When submitting an Institutional Claim for the Client, the Attending Physician will appear on the claim as the Attending Provider.
Step 1: Select Institutional as the Claim Type at the Funder Level
After selecting +Add Funder in Accounting>Accounting Settings>Funders, select Electronic Billing as the Funder Type. Next, select Institutional as the Claim Type.
Complete the other required fields and then click Save.
Step 2: Enter Information Required for Institutional Claims at the Bill Code Level
Once you have created a Funder with Institutional-type Claims, you can create your Bill Code in Accounting>Accounting Settings>Bill Codes. Click +Add Bill Code and select the Funder you created in Step 1.
Once you select a Funder with Claim Type Institutional, the following additional required fields will appear in the Add Bill Code dialogue: Location Indicator, Revenue Code, and Revenue Code Description.
To add a Location Indicator, start typing to select one of the predefined codes for indicating the location of the Visit. Note that a maximum of 48 alphanumeric characters will be accepted in the Revenue Code field and a maximum of 80 alphanumeric characters will be accepted for the Revenue Code Description (no special characters permitted).
When you have completed all required fields, click Save.
Step 3: Generate Claims for the Funder
Once Visits tied to the Bill Code and Funder created in Steps 1 and 2 have been approved, you can generate claims to send to the clearinghouse by selecting the Funder in the Electronic Billing Summary.
On the Electronic Billing Summary, you will be able to filter Funders by Electronic Billing Funder Type (Institutional or Professional).
Click the Funder name to open their claims list and select Generate Claims.
Step 4: Edit the Claim Summary to Add Institutional Claim Details
Once you have generated an Institutional Claim from the Funder's claims list, click View to review the claim details.
In the Claim Summary, you will see the following additional fields in the Claim Summary: Type of Bill Code, Revenue Code (Revenue Code | Revenue Code Description), Priority (Type) of Claim, Point of Origin for Claim, Patient Discharge Status, and Value Codes.
To add or edit any of these values, click the icon. Note that you can only edit the Claim Summary when the claim is Open.
In the Edit Claim Summary dialogue, you can enter and edit values for the required Institutional Claim fields.
For the Type of Bill Code - Frequency field, the option selected by default will be 3. Interim (Continuing Claims) as 3 should be the Frequency for most submitted claims. However, you can change the value to any of the other predefined options in the dropdown if necessary. For instance, if you are submitting a first claim for a Funder, you should select 2. Interim (First Claim), or if you are submitting the last claim for a Funder, you should select 4. Interim (Last Claim). Other options include 0. Nonpayment or Zero Claims, 1. Admit through Discharge Claim, and 5. Late charge only.
For the Priority (Type) of Admission field, 9. Information Not Available will be selected by default but can be changed to any of the other predefined values (1. Emergency, 2. Urgent, 3. Elective, 4. Newborn, or 5. Trauma). For Point of Origin for Admission or Visit, 9. Information Not Available will also be selected by default but can be changed to any of the other options if necessary (1. Physician Referral, 2. Clinic Referral, 3. HMO Referral, 4. Transfer from Hospital, 5. Transfer from SNF, 6. Transfer From Another Health Care Facility, 7. Emergency Room, or 8. Court/Law Enforcement).
To add a Value Code to the claim, select the +Add Value Code button.
In the Code field, start typing to select one of the predefined codes. Enter the Amount and then click Save. You can add up to 12 Value Codes to a claim.
The Revenue Code and Revenue Code Description displayed correspond to the values set on the Bill Code but can be adjusted as necessary.
When you have finished editing the Claim Summary, click Save.
Step 5: Prepare Claims and Send 837
Once you are ready to send a claim, you can select Mark for 837 Preparation and then click Prepare Claims from the Funder's list of claims. Once the claim is prepared, an invoice will also be created in Accounting>Billing>Invoices.
Once the claims have been prepared, you will see the option to Send 837. Selecting this button will send prepared claims to the clearinghouse.
Note that once an Institutional Claim has a status of Paid or Denied, you can revise and resend the claim following the same steps as you would for a Professional Claim.