How do I generate electronic billing claims?

Once you have approved visits for a service funded through electronic billing, you can generate and send claims from ACC to the payor through the clearinghouse or by direct import to your payor's portal. 

• Before generating claims
• Generate electronic claims 
  • Troubleshooting 
  • Important notes for generating claims
• Bulk generate electronic claims using billing periods
  • Read-only claims list
• Regenerate claims
• Payor summary and claim status
  • Understanding 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

• 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.

• 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

• 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. 

• Visits for institutional claims are also grouped by facility code, and visits for professional claims are grouped by place of service. 

• 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.)

• 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. ⚠

1. Go to Accounting > Billing > Billing Period > +Create Billing Period.

2. Choose either:

• 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. ⚠

Regenerate claims 

For claims adjusted due to changes to visits, bill rates, client information, and other reasons, they can be regenerated in bulk (through the Billing Review and Invoice Management screens) and individually through the single claim details screen—all while preserving the original claim ID. The claim ID column on any grid view also displays the claim number and a version number; for example, “123 - 1” represents one claim regeneration. 

Requirements and important notes

• The ability to regenerate claims is protected by an ACL for Admin Portal Roles called “Regenerate Medicaid Claims,” which can be enabled for a user under Settings > Roles & Permissions within the Accounting folder.
• Claims will be regenerated for the same cut-off date originally selected. 
  • New billable items not on the invoice will be picked up. 
  • Existing billable items are regenerated to pull in new source data. 
• The regenerated claim will go into a Prepared status.
• Claim regeneration is allowed from any claim status, including Sent, Paid, and Denied. 
• The ICN from the original claim is preserved and kept for the new claim. 
• If a claim has an ICN, the claim will be sent with a 7 in Loop 2300 - CLM05-03 (Claim Frequency Type Code). 
• Existing applied payment transactions are kept.
• For Data Exploration and Reports, the latest claim ID format will be used: claim number and version number (for example, "123-1").
• When claims are regenerated, existing sales transactions in prior accounting periods are preserved, and new transactions are added to the current period. This means history is preserved, and accounting exports for prior periods return the same data.
  • For example, if a claim was sent on 1/1/2024 for $100 and then regenerated on 9/26/2024 for $105, these are the accounting transactions:

    • 1/1/2024 Sale Transaction for $100

    • 9/26/2024 Void Transaction for ($100)

    • 9/26/2024 Sale Transaction for ($105)

• Currently, partial payment returns do not move to the new claim version in claim regeneration. You must add a Cancel Cash Receipt to the latest claim version against the payment.

Regenerate claims in bulk under Billing Review 

1. Go to Accounting > Billing > Billing Review.

2. Select Regenerate claims.

3. Choose one or more claims you would like to regenerate.

4. Select Regenerate claims.

5. Review details in the dialog.

6. Confirm by selecting Regenerate. 

Regenerate claims in bulk under Invoice Management

1. Go to Accounting > Billing > Invoice Management.

2. From the More Actions dropdown, select Regenerate. 

3. Choose one or more claims you would like to regenerate.

4. Select Regenerate.

5. Review details in the dialog.

6. Confirm by selecting Regenerate. 

Regenerate a single claim 

1. Go to Accounting > Billing > Electronic Billing Summary v2.

2. Select View on the payor for which you want to regenerate a claim.

3. On the claims list, select View on the claim you want to regenerate. 

4. Select Regenerate.

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.

Learn more

• How do I review electronic billing claim details? 
• How do I prepare and send electronic billing claims?
• How do I manually update the status of an electronic billing claim?
• How do I make sure that all approved visits are billed?
• How do I void an electronic billing claim?