Designed to accommodate the needs of the U.S. Medicaid market, AlayaCare’s electronic billing integration and workflows allow agencies to create and manage claims within the web application and export the 837 to send to the correct electronic billing payor.
To use Electronic Billing, the Electronic Billing Integration Feature Flag must be turned on in Settings>All Settings>Features.
- Configuring electronic billing
- Understanding the time bank
- Generating claims
- Reviewing claim details
- Preparing and sending claims
- Opening and closing claims
- Adding transactions to service lines
- Revising billing details on claims
- Manually updating a claim's status
- Voiding a claim
- Accounting for clawbacks
- Exporting claims
Configuring electronic billing
To bill services to an electronic billing payor, you must first create electronic billing payors and then create corresponding bill codes.
When creating an electronic billing payor, you must select professional or institutional as the claim type and complete the fields required for each type. For more details, see How do I create an electronic billing payor?
When creating bill codes for electronic billing payors, you must select a billing increment. The other required fields will vary depending on whether the claim type is professional or institutional.
To learn more, see How do I set up electronic billing in AlayaCare?
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 client has a single visit on one day that lasts 1.5 hours, the billing increment is 60 minutes, and the claim generation frequency is per day, 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. Rounding takes place at the service line level.
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 payor.
Adjustments to account for banked time occur when sending a claim. If a bank adjustment is made, a credit note or debit note transaction will be created at the service line level 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.
Generating claims
To generate claims for recent services, navigate to Accounting>Billing>Electronic Billing Summary v2 and locate the electronic billing funder for which you wish to generate claims.
From this screen, you will be able to see the last visit cut-off date and the number of claims in each status for every electronic billing funder.
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 to open the funder’s claims list.
Any claims that have already been generated for the funder in the date range will be displayed in the list. You can filter this list by claim ID or internal control number, client name, service date range, claim status, resubmitted (yes or no), open or closed claims, client tags as well as for claims with an unpaid balance or clawbacks.
Click generate claims to begin the claim generation process.
Once the background job has finished, the new claims will appear in the list. Note that you may need to refresh the page to see the claims.
To learn more, see How do I generate electronic billing claims?
Reviewing claim details
You will see a summary of the claim details followed by the total billed and amount due as well as any payments or adjustments that have been made on the claim. The service lines section contains details about the individual visits included on the claim while the claim history section represents a log of changes to the claim.
Professional claim example:
Institutional claim example:
To learn more, see Reviewing electronic billing claim details.
Preparing claims and sending the 837
Once all visits on the claim have been approved, you can prepare the claims for sending. You can prepare all the claims from the funder from the claims list by selecting prepare claims.
You will then be able to select which draft claims you wish to prepare for sending by checking the box next to the claim or at the top of the list to select all claims. Once you have made your selection, click prepare selected claims.
Once a claim has been prepared, the 837 can be sent to the funder. Select the send 837 button from the funder’s claims list to send all claims in prepared status.
Selecting send will change the status of prepared claims to sent. While the claim is in sent status, you will not be able to edit the claim by voiding it, revising it, adding transactions, or editing the claim summary.
When you save the claim, the sales transactions for each service line will be created. You can review the invoices created for each service line by going to Accounting>Billing>Invoices.
To learn more, see How do I prepare and send electronic billing claims?
Opening and closing claims
Claims with a status of draft or prepared are considered open, which means the claim and its service lines can be edited. Claims with a status of acknowledged are always locked for editing as they are still being processed. Claims that have a status of sent, accepted, rejected, denied, or paid are closed by default but can be reopened by a user in a role that has the ACL open/close claims.
Only an open claim can be prepared, sent, or edited. To open a closed claim, select the open button.
To lock a claim for editing, click the close button.
Adding transactions to service lines
Transactions can be added to service lines on open claims with a status of rejected, paid, or denied. You can add transactions by selecting the add transaction button at the top of the claim details screen or by going to the accounting tab in the service lines section of claim details and clicking add transaction.
In the add transaction(s) dialogue, select the type of transaction you would like to add (payment, cancel cash receipt, write-off, debit note, or credit note) and then complete the required fields.
To learn more, see How do I add transactions to electronic billing claims?
Revising billing details on a claim after sending
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, select the revise button from the claim details screen.
If you have already edited the claim in the clearinghouse, select revise claim to reconcile with clearinghouse. If you wish to revise the claim and then resend it to the clearinghouse, select revise claim in AlayaCare and resend to clearinghouse.
Next, edit the bill codes, amount billed, and units sent for any of the service lines on the claim.
To learn more, see How do I revise billing details on a claim?
Manually updating 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. 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 begin, open a claim and click the 
icon next to the status you wish to change.
In the edit claim status dialogue, select the new status. For accepted claims, you can select either paid or denied. For denied claims, you can only select paid.
Check whether you wish to allow the internal control number to remain empty or add the transactions after changing the status. If you check this box, you will be prompted to enter the transactions for the service lines after saving the new status. If you leave the box unchecked, the status will be updated without adding a payment or write-off transaction to any service lines on the claim.
When you are ready, click save.
If chose to add transactions to the service lines, second dialogue will open to allow you to choose how you wish to apply transactions associated with the status change.
To learn more, see How do I manually update the status of an electronic billing claim?
Voiding a claim
The void button will be available for all draft and prepared claims as well as any open claims with a status of rejected, paid, or denied that have an internal control number (adjudication number).
To void a claim, select the void button on the claim details screen.
When voiding a rejected, paid, or denied claim, you will have two options in the void dialogue. You can either resubmit the claim to the payor after voiding it or, if you have already voided a claim in the clearinghouse, you can mark the claim as void in AlayaCare so that it matches the clearinghouse.
To learn more, see How do I void an electronic billing claim?
Accounting for clawbacks
835 EDI files can contain a negative value adjudication line item on a claim that has already been paid in situations where a funder has overpaid for a service on a claim. 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, select the filter icon and turn on the clawback flag.
Exporting claims
If you are not using a clearinghouse to send claims to electronic billing payors, you can export 837 files manually from AlayaCare and send them directly to payors. You can download the 837 and view the details of claims included on the 837 regardless of whether you are sending claims electronically or manually for an electronic billing payor.
To view and download the 837 for a client and an electronic billing payor, go to Accounting>Billing>Electronic billing summary v2 and select the export tab.
To learn more, see How do I export an 837 file?