- Before generating claims
- Generate electronic claims
- Bulk generate electronic claims using billing periods
- Payor summary and claim status
Before you begin
Before proceeding, you must approve the visits you want to generate claims for.
Generate electronic claims
1. Go to Accounting > Billing > Electronic Billing Summary v2, where you will see a list of electronic billing payors you had previously created. (Learn more about this view.)
2. Select View on the payor you want to generate claims for.
3. Any claims previously generated within the filtered date range will appear on this list. Select Generate claims.
4. A dialog will appear with a message that varies depending on the claim grouping selected for the payor, as claims can only be generated at the end of a frequency. Select a Visit cut-off date.
5. Select Generate claims.
6. Once you see the message "Claims generation finished," the claims will appear on the list.
7. To view details for each claim, select View.
Troubleshooting
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If claims do not appear, you may need to refresh the page. A quick way to refresh is to switch one of the toggle buttons on and off: Unpaid balance, Clawback, or Issue logs.
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If you see a message that claim generation failed or was only a "partial success," select the
icon to bring up the Background Job Report, where you can review errors and learn why claim generation was unsuccessful. ⚠ To prevent visits from being left unbilled, promptly address any errors identified in the Background Job Report. More info: How do I make sure all approved visits are billed? ⚠
Important notes for generating claims
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Multiple visits with multiple bill codes can all appear on the same claim, as long as they are for the same client and payor, and are grouped correctly under Claim Grouping in the Electronic Billing Payor screen.
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Visits for institutional claims are also grouped by facility code, and visits for professional claims are grouped by place of service.
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All visits on a single date of service for a client must be approved for the date of service to be included in the claim. Any unapproved visits on a date of service will result in that date of service not being included in the new claims. This date of service will be picked up in the next claim generation job once all visits have been approved. (You can build a report in Data Exploration to identify visits being held back for this reason.)
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Agencies on Medicaid can request a feature that automatically fetches the member number linked to the authorization, whenever you generate a claim. With this feature enabled, manually inputting member numbers with claim generation would no longer be required. Please create a support ticket to request enablement.
Bulk generate electronic claims using billing periods
You can bulk-generate claims for multiple electronic billing payors within the billing period creation workflow. This option is particularly efficient if you have numerous payors.
⚠ This feature is available to agencies using Billable Item Management, available by request. ⚠
- To generate claims for all electronic billing payors, under Funder Type, select Electronic billing.
- To generate claims for specific electronic billing payors, under the Funder dropdown, select those electronic billing payors. The payors shown in the dropdown depend on the Billing Frequency you have selected in this dialog. (The billing frequency for payors gets configured in the add/edit electronic billing payor screen.)
3. Save and Generate.
Read-only claims list
After bulk-generating claims, you can find the claims on a read-only claims list within the Billing Period area. Go to Accounting > Billing > Billing Period > View > Invoices > Claims.
⚠ To prepare and send claims, you will still have to follow the existing workflow at the payor level. ⚠
Payor summary and claim status
From Accounting > Billing > Electronic Billing Summary v2, you will see a list of electronic billing payors and associated claim details, such as claim type (professional or institutional), last visit cut-off date, last sent date, and the number of claims in a particular status. Select View on the payor to see their claims list.
Understanding claim status
| Claim status | What it means |
|
Draft |
The claim has been generated, but not prepared or sent. Claims in this status will not be sent. |
| Prepared |
The claim has been generated and is ready to send. This claim would have been actively moved from Draft to Prepared status. This decision tells the system that you want to bill for this claim. If a claim was moved to Prepared status by mistake, you can "unprepare" a claim. |
| Sent |
An 837 file has been created. If you have an integration with our supported clearinghouses, such as Waytar, the file will be automatically sent through the integration. If your agency does not have a clearinghouse integration, you will need to manually export the 837 EDI file to submit to your payor or alternate clearinghouse. |
| Acknowledged | The clearinghouse has received a 999 EDI file for the claim. |
| Accepted | The clearinghouse has received a 277 EDI file and has approved it for sending to the payor. |
| Rejected | The clearinghouse has received a 277 EDI file but it will not be sent to the payor due to an error. |
| Paid | The clearinghouse has received an 835 EDI file and payment from the payor. |
| Denied | The clearinghouse received an 837 EDI file and has refused payment. |
| Void | The claim has been voided. |
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