How do I generate electronic billing claims?

Once the visits for a service funded through electronic billing have been approved, you can generate claims and begin the process of sending claims from AlayaCare to the payor via the clearinghouse.

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. 

You can filter by funder, funder status, claim type, or service date range. By default, the range will be set to the last 60 days.

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.

Note that the claims can only be generated at the end of the frequency. If it is not currently possible to generate claims for the funder, the generate claims button will be disabled. Hover over the button to see the reason why the button is disabled:

The message displayed in the generate claims dialogue will depend on the claim breakdown frequency selected for the funder. Select a visit cut-off date (defaults to today’s date) and click generate claims.

No frequency:

Per day:

Per week:

Per month:

Note that 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 according to the correct claim billing frequency. Visits for institutional claims are also grouped by facility code, and visits for professional claims are grouped by place of service. Visits are also grouped by the prior authorization number entered on the 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. 

Note that no more than 99 service lines (visits) can appear on a single claim due to 837 EDI file limitations. A service limit under 99 may be set on the individual payors. If a claim will contain more service lines than the limit on the electronic billing payor allows ad the service lines have different bill codes, some of the visits will be grouped into a second claim during the claim generation process. If the additional service lines do not have different bill codes and thus cannot be grouped into a second claim, an error will be displayed in the background job report.

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.

If the background job failed or was only a partial success, click the icon next to the status to review the errors.

In the background job report, the error description will describe the reason claim generation was not successful.

The following situations will generate error messages:

• The same date of service appears on multiple claims. In this situation, you should void the existing claim causing a conflict and generate the claims again so that all visits on the same day can be grouped together.
• No visits were found during the date range for which claim generation was run.
• The effective date of the bill code was after the visit date, which prevented a claim from being generated.
• The service line limit set on the payor was reached, and the visits contain the same bill code and thus could not be split into a new claim. You should try increasing the service line limit or update the bill code on some of the visits to resolve issue.

⚠️ Make sure to address any errors identified in the background job report in a timely manner to prevent visits from going unbilled. To learn more, see How do I make sure that all approved visits are billed?

To review the claim details for individual claims, click the View button.

⚠️ Since August 2022, agencies on Medicaid now also have access to a “Authorization/claims linkage” feature flag. Turning it on means that ACC will automatically fetch the member number linked to the authorization, whenever users generate a claim. If your organization uses Medicaid and you still need to automatically input the member number while generating claims, please contact us.