Chapter 25: Claims Center & Billing

Overview

The Claims Center is where completed patient visits are converted into billable insurance claims. This module manages the entire billing lifecycle from visit eligibility through claim generation, submission, payment posting, and denial management. Understanding how claims work is essential for maintaining healthy revenue cycles and ensuring your agency gets paid for services provided.

Understanding Claims and Billing

What is a Claim?

A claim is a formal request for payment submitted to an insurance payer (Medicare, Medicaid, or private insurance) for home health services provided to a patient. Each claim contains:

Patient information (name, DOB, insurance details)
Service details (visits performed, dates of service, clinicians)
Billing codes (HCPCS codes for services, HIPPS codes for Medicare)
Charged amounts (based on payer rate schedules or Medicare PDGM rates)

Medicare vs Private Insurance Billing

The system handles two fundamentally different billing models:

Medicare/Medicaid (PDGM - Patient-Driven Groupings Model)

Billing Period: 30-day periods (Period 1 = Days 1-30, Period 2 = Days 31-60)
Reimbursement: Based on HIPPS code (single rate regardless of number of visits)
Claim Timing: One claim per 30-day period per episode
Visit Rates: Individual visits show $0.00 (informational only)
Total Claim Amount: HIPPS rate (e.g., $3,500 for the 30-day period)
Prerequisite: OASIS must be submitted to CMS and status = ACCEPTED before billing

Example:

Patient has Medicare
Episode: Jan 1 - Feb 29, 2026
HIPPS code: 1CABA (determined from OASIS assessment)
Period 1 (Days 1-30): 8 visits performed → Claim amount = $3,200 (HIPPS rate)
Period 2 (Days 31-60): 5 visits performed → Claim amount = $3,200 (same HIPPS rate)

Private Insurance / Managed Care (Fee-for-Service)

Billing Period: Flexible (bill whenever visits accumulate, no 30-day requirement)
Reimbursement: Based on Fee Schedule (per-visit rates configured for each payer and visit type)
Claim Timing: Can bill immediately after visits complete, or batch multiple visits into one claim
Visit Rates: Each visit has its own rate (e.g., SN Visit = $150, PT Visit = $180)
Total Claim Amount: Sum of all visit rates
Prerequisite: Prior Authorization (PA) must be approved (for payers requiring PA)

Example:

Patient has Blue Cross Blue Shield
3 visits performed: 2 SN visits ($150 each), 1 PT visit ($180)
Total claim amount = $150 + $150 + $180 = $480

Visit Eligibility for Billing

Not all completed visits can be billed. The system applies strict eligibility rules to ensure only valid visits appear in the Claims Center.

Required Conditions (All Must Be Met)

Condition	Description	Why It Matters
Visit Status = `Completed`	Clinician has checked out of the visit	Incomplete visits cannot be billed
Visit Note Status = `Approved`	The clinical document (visit note) passed QA review and is approved	Unapproved documentation doesn't meet insurance standards
Care Order Status = `Active` or `Discharged`	The patient's episode is active or recently discharged	Closed or On Hold episodes are not billable
Visit marked as `isBillable = true`	The visit hasn't been marked as non-billable	Some visits are non-billable (e.g., courtesy visits, training)
Visit NOT already on a claim (`claimId = null`)	The visit hasn't been billed yet	Prevents double-billing
Patient has Primary Payer	Patient has an insurance payer assigned	Cannot bill without knowing who to bill

Additional Filters for Specific Payers

Medicare-Specific Rules

Rule	Description
OASIS Submitted and Accepted	The OASIS assessment for this episode must be submitted to CMS and status = `ACCEPTED`
SOC/Recert/ROC Visits Excluded	OASIS visit types (Start of Care, Recertification, Resumption of Care) cannot be billed separately
Post-Discharge Visits Excluded	Visits that occurred after the discharge date (M0906 from Discharge OASIS) are automatically filtered out

Private Insurance Rules

Rule	Description
Prior Authorization (if required by payer)	PA must be approved and have remaining units
Fee Schedule	Rate must be configured for (payer + visit type) combination

Claims Center Interface

Claims Center Main View

Dashboard Statistics Cards (Top Section)

Three KPI cards provide a real-time overview of your billing status:

Card	Color	Meaning	Calculation
Ready to bill	Blue	Number of completed visits eligible for billing but not yet on a claim	Count of visits meeting all eligibility conditions
Submitted	Gray	Number of claims submitted to insurance and awaiting payment	Claims with status = `Submitted`
Denied	Red	Number of claims denied by insurance	Claims with status = `Denied`

These stats are cached for 90 seconds and refresh automatically when you generate, submit, or update claims.

Four Main Tabs

The Claims Center is organized into four tabs, each representing a stage in the billing workflow:

1. Ready for Billing Tab

Shows patients who have unbilled completed visits
Grouped by patient (one row per patient showing how many visits and estimated amount)
Primary action: "Review & Bill" button to generate claims

2. Claims Tracking Tab

Shows all generated claims organized by status
Sub-tabs:
- Ready to Submit - Claims generated but not yet sent to insurance
- Submitted - Claims sent to insurance, awaiting payment
- Partially Paid - Claims where insurance paid part but not full amount
- Paid - Fully paid claims (balance = $0)
Primary actions: Mark as Submitted, Export 837, Post Payment

3. Denial Management Tab

Shows all denied claims requiring investigation and resolution
Helps you identify patterns (which payer denies most, what reasons)
Primary actions: Resubmit (after correction), Write Off (if unrecoverable)

4. Void Tab

Shows voided claims (cancelled before or after submission)
Claims voided to release visits back to "Ready for Billing"
Read-only (voided claims cannot be edited)

Ready for Billing Tab: Detailed Walkthrough

Ready for Billing Tab

Patient List Table

The table shows patients grouped by unbilled visits:

Column	Description
Patient Name	Patient's full name. Shown with an avatar containing initials.
Payer	Primary insurance payer name (e.g., "Blue Cross Blue Shield").
Unbilled Visits	Number of completed, approved visits that haven't been billed yet (e.g., "1 Visit").
Estimated Amount	Projected claim amount. Shows "⚠ Rate Missing" if Fee Schedule rates are not configured. For Medicare, shows the HIPPS rate.
Last Billed	Date of the most recent claim for this patient. Shows "Never" if patient has never been billed.
Actions	"Review & Bill" button - Opens the billing modal to select visits and generate a claim.

Filters (Top of Table)

Payer Filter:

Dropdown showing "All Payers" or specific payer names
Filters the patient list to show only patients with selected payer
Useful for batch-submitting claims to one insurance company

Date Range Filter:

Options: "All Time", "Last 7 Days", "Last 30 Days", "This Month"
Filters based on last billed date
Helps identify patients who haven't been billed recently

Refresh Button:

Icon button (circular arrow) on the right
Reloads the Ready for Billing list
Use after visits are completed/approved to see updated counts

Interpreting "Estimated Amount"

The Estimated Amount column shows different things based on payer type:

Medicare Patients

Shows the HIPPS rate for the current billing period
Example: "$3,500.00"
If HIPPS code is missing or rate not configured: "⚠ Rate Missing"

Private Insurance Patients

Shows the sum of individual visit rates from Fee Schedules
Example: 3 visits → 2 SN ($150 each) + 1 PT ($180) = "$480.00"
If any visit type lacks a rate: "⚠ Rate Missing"

Warning: "⚠ Rate Missing"

One or more visits cannot be billed because the rate is not configured
You must either:
- Configure the missing rate in Fee Schedule Setup (for private insurance)
- Configure the missing HIPPS rate in Payer Setup (for Medicare)
- Manually enter a rate when generating the claim (override)

Generating Claims: Step-by-Step

Step 1: Click "Review & Bill"

Click the blue "Review & Bill" button for a patient in the Ready for Billing table.

Step 2: Review Patient and Visits

The Bill Patient modal opens:

Bill Patient Modal - No Rate

Modal Header:

Title: "Bill Patient: [Patient Name]"
Subtitle: "Payer: [Payer Name] | Generating Claim [Claim Number Preview]"
- Claim number preview format: CLM-YYYY-XXXX (actual number assigned by backend)

For Medicare Patients:

Bill Patient Modal - With Rate

The modal shows a Medicare HIPPS Information section at the top:

Field	Description	Editable?
Detected HIPPS Code	HIPPS code from the approved OASIS assessment (stored in Care Order). Example: `1CABA`.	No (read-only chip)
Reimbursement Rate	The rate for this HIPPS code. Automatically looked up from Payer Settings. If missing, field is red with error message.	Yes - You can override the rate if needed

Validation Alert: If the HIPPS rate is missing:

Field shows error styling (red border)
Helper text: "Rate for HIPPS code not found in Payer Settings. Please enter manually."
You must enter a rate before generating the claim

For Private Insurance Patients:

No HIPPS section. Rates are shown per visit in the visits table.

Step 3: Select Visits to Bill

The modal displays a Visits Table with the following columns:

Column	Description
Select	Checkbox to include this visit on the claim. Auto-selected by default unless visit has authorization alerts.
Billable	Checkbox showing if visit is marked as billable. You can toggle this to mark visits as non-billable (removes from billing queue).
Visit Date	Date the visit was performed (e.g., "Jan 23, 2026").
Type	Visit type (e.g., "OASIS E1 Transfer", "HHA Visit", "PT Evaluation"). May show authorization alert icons.
Clinician	Name of the clinician who performed the visit (e.g., "Abeble Godeen").
Rate ($)	For Medicare: Shows "$0.00" (visits are informational only). For Private Insurance: Shows the rate from Fee Schedule or allows manual entry if rate is missing.
Status	Shows "Ready" or authorization alert chips ("No Authorization", "Exceeds Limit").

Visit Selection Logic

Auto-Selected Visits:

Have no authorization alerts
Are marked as billable (isBillable = true)

Disabled Visits (Cannot Select):

Have authorization alerts:
- "No Authorization" (MISSING_AUTH) - Critical error, shown with red error icon
- "Exceeds Limit" (EXCEEDS_LIMIT) - Warning, shown with yellow warning icon

Authorization Alerts Explained:

Alert Type	Icon	Meaning	Action Required
MISSING_AUTH	Red exclamation mark	Visit has no valid Prior Authorization. PA is either missing, expired, exhausted, or denied.	Go to Prior Authorizations module, create or update PA to approve units for this discipline. Then click "Re-Validate" button.
EXCEEDS_LIMIT	Yellow warning triangle	Visit would exceed the approved PA units. Example: PA approved 10 visits, but 11 visits were completed.	Go to Prior Authorizations module, request extension from insurance to approve additional units. Then click "Re-Validate" button.

Re-Validate Button:

Appears next to authorization alert chips
Clicking it re-checks the PA status for this visit
If PA has been updated (e.g., more units approved), alert clears and visit becomes selectable
Shows loading spinner while validating

Rate Overrides (Private Insurance Only)

For private insurance visits:

If Fee Schedule rate exists, it's auto-populated
If missing, the rate field is empty with red error styling
You can manually enter a rate to override
Example: Rate configured = $150, but you want to bill $160 for this specific visit → Enter $160 in the rate field

Step 4: Review Total and Generate Claim

Total Claim Section (bottom of modal):

Shows the calculated total claim amount
Formula:
- Medicare: Total = HIPPS rate (regardless of number of visits)
- Private Insurance: Total = Sum of (selected visit rates)

Validation Errors:

The "Generate Claim" button is disabled if:

No visits are selected
Any selected visit has a missing rate (and no override entered)
For Medicare: HIPPS rate is missing (and no override entered)

Error Messages:

If no visits selected and all have authorization alerts: "Cannot generate claim: X visit(s) have authorization errors and cannot be billed. Please resolve authorization issues first."
If missing rates: "Please provide rates for all selected visits before generating the claim."
Red alert banner at bottom: "Please provide rates for all selected visits before generating the claim."

Step 5: Claim Generation Process

When you click "Generate Claim CLM-2026-XXXX":

Backend Actions:

Validation: Re-checks all visit eligibility conditions
Rate Lookup:
- Medicare: Looks up HIPPS rate from Payer Settings (or uses override)
- Private: Looks up Fee Schedule rates for each visit (or uses overrides)
30-Day Period Validation (Medicare Only):
- Ensures all visits are in the same 30-day period
- Error if visits span Period 1 and Period 2: "Medicare claims cannot span payment periods. 3 visit(s) are in Period 1 (Days 1-30) and 2 visit(s) are in Period 2 (Days 31-60). Please select visits only from Days 1-30 or Days 31-60."
Claim Number Generation: Assigns unique claim number (format: CLM-YYYY-####)
Claim Record Created:
- Status = Ready to Submit
- totalAmount = calculated total
- balanceDue = totalAmount (initially unpaid)
- claimStartDate = earliest visit date
- claimEndDate = latest visit date
Line Items Created: One line item per visit with:
- chargeAmount = visit rate (or $0.00 for Medicare)
- visitId = linked to visit
- serviceCode = HCPCS code from visit type
Visits Updated: Each visit's claimId field is set to the new claim ID (marks them as billed)
Cache Invalidation: "Ready to Bill" count decreases, claim list refreshes

Success Message: "Successfully generated claim CLM-2026-0002!"

Result:

Modal closes
Patient disappears from "Ready for Billing" table
Claim appears in "Claims Tracking" tab → "Ready to Submit" sub-tab

Claims Tracking Tab: Managing Generated Claims

Claims Tracking Tab

Sub-Tab Structure

The Claims Tracking tab uses a left sidebar navigation with four sub-tabs:

Sub-Tab	Status Filter	Description
Ready to Submit	`status = "Ready to Submit"`	Claims generated but not yet sent to insurance
Submitted	`status = "Submitted"`	Claims sent to insurance, awaiting response
Partially Paid	`status = "Partially Paid"`	Claims where insurance paid part but not full amount
Paid	`status = "Paid"`	Fully paid claims with balance = $0

Claims Table (All Sub-Tabs)

Submitted Claims Tab

The table displays claims with the following columns:

Column	Description
Patient Name	Patient's full name. Clickable link opens patient profile.
Payer	Insurance company name (e.g., "Blue Cross Blue Shield", "Medicare of Texas").
Claim #	Unique claim identifier (e.g., "CLM-2026-0002").
Service Dates	Start → End date of services on this claim (e.g., "1/11/2026 - 1/11/2026" for single-visit claim, or "12/1/2025 - 12/30/2025" for monthly billing period).
Billed Amount	Total amount billed to insurance (e.g., "$77.00" for private insurance, "$3,500.00" for Medicare HIPPS).
Balance Due	Remaining unpaid amount. Initially equals Billed Amount. Decreases as payments are posted. Shows "$0.00" when fully paid.
Status	Color-coded status badge: - Blue "Ready to Submit" - Gray "Submitted" - Green "Paid" - Yellow "Partially Paid"
Actions	Two icon buttons: - Eye icon (View Details) - Three-dot menu (More Actions)

Filters and Search (Top of Table)

Payer Filter:

Dropdown showing "All" or specific payer names
Filters claims by payer

Search Bar:

Search by patient name or claim number
Real-time filtering as you type

Refresh Button:

Reloads claims list
Use after submitting claims externally or receiving payment notifications

Claim Details Modal

Click the eye icon or patient name to open the claim details modal.

Claim Details - Ready to Submit

Header Section

Field	Description
Patient Name	Full patient name (e.g., "Test Start")
Payer	Insurance company (e.g., "Blue Cross Blue Shield")
Claim #	Unique identifier (e.g., "CLM-2020-XXXX")
Total Billed Amount	Total charged to insurance (e.g., "$77.00")
Balance Due	Unpaid amount remaining (e.g., "$77.00" if no payments posted)
Status	Color-coded badge (Green "Ready to Submit")

Activity Log / Notes Section

Text area to add notes or log activity about this claim
Example: "Called insurance on 4/10/26 - representative confirmed authorization is valid"
Click "Save Note" to save
Notes appear with timestamp and user name
Useful for tracking follow-ups, appeal status, or special instructions

Visits Table

Shows all visits included on this claim:

Column	Description
Date of Service	Date the visit was performed (e.g., "1/11/2026")
Service Code	HCPCS code for the service (e.g., "G0299" for RN visit, "G0156" for HHA visit)
Visit Type	Description of the visit (e.g., "OASIS - Death at Home", "HHA Visit")
Clinician	Name of clinician who performed the visit (e.g., "Abeble Godeen")
Billed Amount	Amount billed for this specific visit. For Medicare: always "$0.00" (informational only). For Private Insurance: individual visit rate (e.g., "$77.00").

Total Billed Row:

Bottom row shows sum of all visit amounts
For Medicare: Shows the HIPPS rate here (since individual visits are $0)
For Private Insurance: Sum of all visit rates

Action Buttons (Bottom of Modal)

Button	Availability	Action
Close	Always	Closes the modal
Export Claim	Always	Downloads a CMS-1500 PDF or 837 EDI file for this claim (see Export section below)

Marking Claims as Submitted

After you export a claim and submit it to insurance (via clearinghouse, payer portal, or mail), you must mark it as submitted to track its status.

Step 1: Open Mark as Submitted Modal

From the Ready to Submit sub-tab, click the three-dot menu icon → "Mark as Submitted" (or use the bulk action button if multiple claims selected).

Mark as Submitted Modal

Step 2: Confirm Submission

The "Mark as Submitted" modal displays:

Header:

Title: "Confirm Submission"
Question: "Did you upload the 837 file to the Payer Portal?"

Claim Information Box:

Claim Number (e.g., "CLM-2026-0002")
Patient name (e.g., "Amina Ali")

Confirmation Checkbox:

Text: "Yes, I have uploaded the 837 file to the payer portal"
Must be checked to enable the submit button

Action Buttons:

Cancel - Closes modal without changes
Mark as Submitted - Changes claim status to Submitted

Step 3: Claim Status Changes

When you click "Mark as Submitted":

Backend Actions:

Claim status changes from Ready to Submit → Submitted
exportedAt timestamp is recorded (if not already set)
Claim moves to the "Submitted" sub-tab

What This Means:

Claim is now "in flight" with the insurance company
You're waiting for payment or denial response
Claim disappears from "Ready to Submit" sub-tab
Claim appears in "Submitted" sub-tab

Submitted Claims Tab

Posting Payments to Claims

When insurance sends payment (via check, EFT, or ERA), you must record it in the system.

Step 1: Open Post Payment Modal

From the Submitted sub-tab, click the three-dot menu icon for a claim → "Post Payment".

Step 2: Fill in Payment Details

The Post Payment modal includes:

Field	Description	Required?
Payment Amount	Amount insurance paid (can be less than, equal to, or more than billed amount)	Yes
Payment Date	Date the payment was received (from check date or EFT transaction date)	Yes
Check Number	Check number (if paid by check)	No (but recommended)
Payment Method	Dropdown: "Check", "EFT" (Electronic Funds Transfer), "Credit", "Other"	Yes
Notes	Optional note about this payment (e.g., "ERA ID: 12345", "Adjustment reason code: 50")	No

Example:

Billed Amount: $480.00
Insurance Paid: $420.00
Payment Date: April 5, 2026
Check Number: 789456
Payment Method: Check
Notes: "Paid in full per contracted rate. Patient responsibility: $60 co-pay."

Step 3: Payment is Posted

When you click "Post Payment":

Backend Actions:

Payment Record Created in the payments table with all entered details
Balance Recalculated:
- Formula: balanceDue = totalAmount - SUM(all payments)
- Example: $480 billed - $420 paid = $60 remaining
Claim Status Auto-Updated:
- If balance = $0 → Status changes to Paid
- If balance > $0 and < total → Status changes to Partially Paid
- If balance = total (no payment yet) → Status remains Submitted

Result:

Claim moves to "Paid" sub-tab (if fully paid) or "Partially Paid" sub-tab (if partial)
Balance Due column updates to show remaining amount

Paid Claims Tab

Posting Multiple Payments

If insurance pays in multiple installments:

Post first payment (e.g., $200) → Status becomes Partially Paid, balance = $280
Post second payment (e.g., $280) → Status becomes Paid, balance = $0

Overpayment Handling

If insurance pays more than billed:

Example: Billed $480, insurance paid $500
Balance becomes -$20 (negative balance = credit)
Status becomes Paid
The $20 credit can be applied to future claims or refunded to insurance

Denial Management Tab

When insurance denies a claim, it moves to the Denial Management tab for investigation and resolution.

How Claims Become Denied

Path 1: Mark as Denied (Manual)

You receive a denial letter or ERA from insurance
Go to Claims Tracking → Submitted sub-tab
Click three-dot menu for the claim → "Mark as Denied"
Modal opens to confirm denial (similar to mark as submitted)
Claim status changes to Denied
Claim moves to Denial Management tab

Path 2: Post Payment with Full Denial

Insurance pays $0 with denial codes
You post payment amount = $0
Claim status becomes Denied (because balance = total amount, indicating no payment)

Denial Management Table

Same columns as Claims Tracking, but filtered to show only status = "Denied" claims.

Column	Value Example
Patient Name	"ulala Haji"
Payer	"Blue Cross Blue Shield"
Claim #	"CLM-2025-0010"
Service Dates	"12/11/2025 - 12/11/2025"
Billed Amount	"$121.00"
Balance Due	"$121.00" (full amount unpaid)
Status	Red "Denied" badge
Actions	Eye icon (View Details), Three-dot menu (Resubmit, Write Off)

Actions for Denied Claims

Click the three-dot menu for a denied claim:

Action	Description
View Details	Opens claim details modal to see visits and add notes
Resubmit	Corrects the claim and changes status back to `Ready to Submit` for resubmission
Write Off	Marks claim as uncollectible, sets balance to $0 (does not change status to Paid - remains Denied)

Resubmitting Denied Claims

Resubmit Claim Modal

When to Resubmit

Resubmit a claim when:

Denial was due to correctable error (wrong code, missing authorization number, incorrect date)
You've obtained additional documentation insurance requested
You've appealed and insurance approved the appeal

Do NOT resubmit if:

Denial is final and insurance won't reconsider
Claim is not worth the effort (low amount, high collection cost)
Patient is responsible for the balance (co-pay, out-of-pocket)

Resubmit Process

Step 1: Open Resubmit Modal

Go to Denial Management tab
Click three-dot menu for the denied claim
Select "Resubmit"

Step 2: Review Claim Information

The modal shows:

Title: "Resubmit Denied Claim"
Description: "This will change the claim status back to 'Ready to Submit' so you can correct and resubmit it."
Claim Number (e.g., "CLM-2025-0010")
Patient name (e.g., "ulala Haji")
Info Note: "After resubmitting, you can download a new 837 file and submit it to the payer."

Step 3: Confirm Resubmit

Click the blue "Resubmit Claim" button.

Backend Actions:

Claim status changes from Denied → Ready to Submit
Claim moves from Denial Management tab to Claims Tracking → Ready to Submit sub-tab
Cache invalidated (stats updated)

What Happens Next:

Go to Claims Tracking → Ready to Submit
Find the resubmitted claim
Export a new 837 file or CMS-1500 PDF
Submit it to insurance (via clearinghouse or payer portal)
Mark as Submitted again

Note: Resubmitting does NOT change the visits, line items, or amounts. It only resets the claim status to allow another submission attempt.

Writing Off Uncollectible Claims

If a denied claim cannot be collected, you can write it off to remove it from your accounts receivable.

When to Write Off

Scenario	Action
Insurance final denial	After appeal period expires, write off the claim
Patient unresponsive	Patient owes co-pay but hasn't paid after multiple attempts
Small balance	Amount is too small to justify collection efforts (e.g., $5 balance)
Bankruptcy	Patient filed bankruptcy and balance is discharged
Death	Patient deceased and estate won't pay (no balance transfer to responsible party)

Write Off Process

Step 1: Open Write Off Modal

Go to Denial Management tab
Click three-dot menu for the denied claim
Select "Write Off"

Step 2: Confirm Write Off

The modal shows:

Warning: Writing off a claim sets the balance to $0 but keeps status as Denied
Claim details (patient, payer, amount)
Checkbox: "I confirm this balance is uncollectible and should be written off"

Step 3: Execute Write Off

Click "Write Off" button.

Backend Actions:

Claim's balanceDue is set to $0.00
Claim status remains Denied (to preserve audit trail showing it was never paid by insurance)
A write-off record may be created (depending on accounting configuration)

Result:

Claim shows balance = "$0.00"
Claim remains in Denial Management tab (status is still Denied, not Paid)
Financial reports show this as a write-off, not revenue

Important Distinction:

Paid Claim: Insurance or patient paid the full amount → status = Paid
Written Off Claim: No one paid, agency absorbed the loss → status = Denied, balance = $0

Voiding Claims

Void Claim Modal

What is Voiding?

Voiding a claim permanently cancels it and releases all associated visits back to the "Ready for Billing" queue. This is useful when:

Claim was generated in error (wrong patient, wrong payer, wrong visits)
You need to regenerate the claim with different visits
Claim was submitted to wrong insurance company

When You Can Void

Claim Status	Can Void?	Why?
Ready to Submit	Yes	Claim hasn't been submitted yet - safe to cancel
Submitted	Yes	Claim was submitted but you discovered an error - void it before insurance processes
Denied	Yes	Claim was denied and you want to recreate it differently
Partially Paid	Yes	Rare, but possible if you want to cancel the claim and refund the partial payment
Paid	NO	Cannot void paid claims - financial integrity rule. Paid claims are locked.
Void	No	Already voided

Voiding Process

Step 1: Open Void Modal

From any Claims Tracking sub-tab (except Paid), click three-dot menu → "Void"
Or right-click the claim row and select Void

Void Claim Modal

Step 2: Review Warnings

The "Void Claim" modal shows:

Header:

Title: "Are you sure?"
Triangle warning icon (red)

Main Warning: "This will void the claim and release all associated visits back to the 'Ready to bill' queue."

Important Notices:

Yellow Warning Box: "Claim [Claim Number] for [Patient Name] will be voided. All visits will be unlocked and available for billing again."
Red Error Box: "This action cannot be undone."

Step 3: Confirm Void

Click the red "Void Claim" button.

Backend Actions:

Claim status changes to Void
CRITICAL: All visits' claimId field is set to NULL
- This "releases" the visits so they're no longer linked to any claim
Visits reappear in "Ready for Billing" tab
You can now generate a new claim with those visits (with corrections)

Result:

Claim moves to "Void" tab
Patient reappears in "Ready for Billing" with those visits
You can regenerate the claim correctly

Use Cases for Voiding

Use Case 1: Wrong Payer Selected

Problem: You generated a claim billing Medicare, but the patient's primary payer is actually Blue Cross.

Solution:

Void the Medicare claim
Visits return to "Ready for Billing"
Update patient's primary payer to Blue Cross (in Patient module)
Generate a new claim (now correctly billing Blue Cross)

Use Case 2: Included Wrong Visits

Problem: Claim includes 5 visits, but 2 of them belong to a different care order (different episode).

Solution:

Void the claim
Visits return to "Ready for Billing"
Review & Bill again, selecting only the correct 3 visits for Episode 1
Generate a separate claim for the 2 visits from Episode 2

Use Case 3: Submitted to Wrong Clearinghouse

Problem: You accidentally uploaded the 837 file to the wrong clearinghouse.

Solution:

Void the claim in the system
Delete the file from the wrong clearinghouse (if possible)
Generate the claim again
Export and submit to the correct clearinghouse
Mark as Submitted

Void Tab: Viewing Voided Claims

Void Tab

What's in the Void Tab?

The Void tab shows all claims with status = "Void".

Table Columns:

Same as Claims Tracking tabs (Patient, Payer, Claim #, Service Dates, Billed Amount, Balance Due, Status, Actions)
Status column shows red "Void" badge
Balance Due shows the original balance (voided claims keep financial totals for audit trail)

Actions Available:

View Details - See the claim details and visits (read-only)
No other actions - Voided claims cannot be edited, resubmitted, or unvoided

Why Keep Voided Claims?

Audit Trail: Shows what claims were generated and then cancelled
Financial Reporting: Voided claims are excluded from revenue calculations
Compliance: Demonstrates you're not double-billing (visit was released and re-billed on a different claim)

Voided Claim Details: When you click "View Details" on a voided claim:

Shows all original information (visits, dates, amounts)
Shows "Void" status badge
No action buttons (read-only)
Visits table may show empty if visits were re-billed on a different claim

Exporting Claims (837 EDI and CMS-1500)

Claims can be exported in two formats for submission to insurance:

Format 1: 837P EDI File (Electronic)

What is 837P?

837P = HIPAA-compliant electronic claim format (P = Professional claims)
Plain text file with standardized segments (ISA, GS, ST, NM1, etc.)
Required by most clearinghouses and payer electronic portals

When to Use:

Submitting to a clearinghouse (e.g., Change Healthcare, Waystar)
Uploading to payer electronic portal (e.g., Availity)
Most efficient for bulk claims

How to Export:

Click "Export Claim" button on claim details modal, OR
From Claims Tracking → Ready to Submit, select multiple claims and click bulk "Download 837"
System generates the 837P file
File downloads automatically (filename: 837P_BATCH_[timestamp].txt)

File Structure Example:

ISA*00*          *00*          *ZZ*AGENCY123      *ZZ*PAYER456       *260410*1200*^*00501*000000001*0*P*:~
GS*HC*AGENCY123*PAYER456*20260410*1200*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*CLM-2026-0002*20260410*1200*CH~
...

Format 2: CMS-1500 PDF (Paper)

What is CMS-1500?

Standard paper claim form (red-outlined boxes)
Used for mailing claims or uploading scanned copies

When to Use:

Submitting to payers that don't accept electronic claims
Printing for patient records or audits
Small volume of claims

How to Export:

Click "Export Claim" → Choose "CMS-1500 PDF"
System generates a filled PDF form
PDF downloads with patient info, services, codes, and amounts

Understanding Claim Statuses: Complete Lifecycle

Status Flow Chart

Ready to Bill (Visits)
    ↓ [Generate Claim]
Ready to Submit (Claim)
    ↓ [Export 837/CMS-1500 & Submit to Insurance]
Ready to Submit (Claim)
    ↓ [Mark as Submitted]
Submitted (Claim)
    ↓ [Insurance Processes]
    ├→ [Full Payment] → Paid (Final)
    ├→ [Partial Payment] → Partially Paid (Can receive more payments)
    ├→ [Denial] → Denied (Can Resubmit or Write Off)
    └→ [Void] → Void (Released back to Ready to Bill)

Status Definitions in Detail

Status	Color	Description	Actions Available	Next Steps
Ready to Submit	Blue	Claim generated, includes selected visits, has claim number, ready to export and send to insurance	Export 837, Export CMS-1500, Edit, Void	Export and submit to insurance, then mark as submitted
Submitted	Gray	Claim sent to insurance, awaiting response (payment or denial)	Post Payment, Mark as Denied, Void	Wait for ERA/EOB from insurance, then post payment or mark as denied
Paid	Green	Insurance paid full amount, balance = $0, claim is closed	View Details, Export (read-only)	None - claim is complete
Partially Paid	Yellow	Insurance paid some but not all, balance > $0	Post Additional Payment, Mark as Denied (remaining balance), Write Off (remaining balance)	Follow up with insurance for remaining balance, or collect from patient
Denied	Red	Insurance denied claim, balance = full amount	View Details, Resubmit (correct and resubmit), Write Off (if uncollectible)	Investigate denial reason, correct error, and resubmit, or write off if not worth pursuing
Void	Red	Claim cancelled, visits released back to billing queue	View Details (read-only)	Visits are now available to bill on a new claim

Medicare-Specific Billing Rules

Medicare billing has unique requirements that differ from private insurance.

1. OASIS Acceptance Requirement

Rule: For Medicare care orders, the OASIS assessment must be submitted to CMS and status must be ACCEPTED before you can generate claims for visits in that episode.

Why: Medicare ties payment to OASIS assessments. Without an accepted OASIS, Medicare has no basis to determine the HIPPS code or approve payment.

Error If Not Met: When trying to generate a claim: "Cannot generate Medicare claim: OASIS submission status is 'READY_TO_SUBMIT'. OASIS must be submitted and accepted before billing Medicare. Please check the OASIS Submissions workspace."

Solution:

Go to OASIS Submissions module
Export the OASIS XML
Submit to CMS via QIES system
Mark as Submitted in the system
Wait for CMS response (usually 24-48 hours)
Mark as Accepted once CMS confirms
Return to Claims Center - visits now appear in Ready for Billing

2. 30-Day Period Validation

Rule: All visits on a Medicare claim must fall within the same 30-day billing period.

Period Definitions:

Period 1: Days 1-30 of the episode (Day 1 = certification start date, Day 30 = start date + 29 days)
Period 2: Days 31-60 of the episode (Day 31 = start date + 30 days, Day 60 = start date + 59 days)

Example:

Episode starts Jan 1, 2026
Period 1: Jan 1 - Jan 30, 2026
Period 2: Jan 31 - Mar 1, 2026

Validation Error: If you try to bill visits from both periods on the same claim: "Medicare claims cannot span payment periods. 4 visit(s) are in Period 1 (Days 1-30) and 2 visit(s) are in Period 2 (Days 31-60). Please select visits only from Days 1-30 or Days 31-60."

Solution:

Generate two separate claims:
- Claim 1: Include only Period 1 visits (4 visits)
- Claim 2: Include only Period 2 visits (2 visits)
Both claims will have the same HIPPS rate (e.g., $3,200 each)

3. HIPPS Code and Rate Lookup

Process:

System retrieves HIPPS code from the Care Order (stored when OASIS was approved)
System looks up the HIPPS rate from Payer Settings (based on HIPPS code and effective date)
If rate is missing, you must manually enter it in the billing modal

Rate Lookup Logic:

Finds rate with HIPPS code matching AND effective date <= earliest visit date
If multiple rates exist, uses the most recent one (by effective date DESC)

Why Effective Date Matters: HIPPS rates change annually (January 1 each year). A visit on Jan 15, 2026 uses the 2026 rate, but a visit on Dec 20, 2025 uses the 2025 rate.

4. Medicare Does Not Use Line Item Rates

In Medicare claims:

Individual visit amounts = $0.00 (informational only, not billed separately)
Total claim amount = HIPPS rate (flat rate for the 30-day period)
Visits are listed on the claim to document services provided, but payment is based on HIPPS, not visit count

Why This Matters: If you provide 3 visits or 15 visits in a 30-day period, Medicare pays the same HIPPS rate. The payment is based on patient acuity and clinical characteristics (captured in OASIS), not visit frequency.

Private Insurance-Specific Billing Rules

1. Fee Schedule Requirement

Rule: For private insurance and Medicaid Managed Care, each visit type must have a configured rate in the Fee Schedule.

How Rates Are Looked Up:

System finds Fee Schedule entry where:
- payerId = patient's primary payer
- visitTypeId = visit type being billed
- effectiveDate <= visit date
If multiple rates exist, uses the most recent one (by effective date DESC)

Missing Rate Handling:

If rate is missing, visit shows "Rate not found" error in the billing modal
You can manually enter a rate override
Better solution: Go to Fee Schedule Setup and configure the rate for future claims

2. Prior Authorization Validation

Rule: If the payer requires prior authorization, the visit must be linked to an approved PA with remaining units.

Authorization Alerts:

MISSING_AUTH: Visit has no valid PA (PA is expired, exhausted, denied, or doesn't exist)
EXCEEDS_LIMIT: Visit exceeds approved PA units

Error Prevention:

Visits with authorization alerts are automatically unselected in the billing modal
Checkbox is disabled (cannot include them on the claim)
Must resolve the PA issue first, then click "Re-Validate" to clear the alert

3. Multiple Claims Per Patient

Unlike Medicare (which requires one claim per 30-day period), private insurance allows flexibility:

Option A: Generate one claim with all unbilled visits (monthly billing)
Option B: Generate separate claims for each visit (immediate billing)
Option C: Group visits by week or other custom period

Recommendation: Bill weekly or bi-weekly for private insurance to improve cash flow and reduce risk of large denials.

Best Practices for Claims Management

1. Bill Medicare Period 1 Claims Immediately

Why:

Period 1 claims can be submitted as soon as Day 1 visits are complete (don't need to wait for Day 30)
Faster billing = faster payment = better cash flow
CMS allows submitting RAP (Request for Anticipated Payment) after first visit

How:

As soon as OASIS is accepted and first few visits are complete, generate Period 1 claim
Even if only 2 visits are complete out of 10 planned, you can bill
Medicare pays based on HIPPS, not visit count

2. Verify Rates Before Mass Billing

Why:

Missing rates cause claim generation to fail
Entering rates manually for every visit is time-consuming
Consistent rates ensure predictable revenue

How:

Before running monthly billing, spot-check a few patients:
- Click "Review & Bill"
- Check if any visits show "Rate not found"
- If rates are missing, go to Fee Schedule Setup and configure them
Once rates are confirmed, proceed with bulk billing

3. Resolve Authorization Alerts Immediately

Why:

Visits with authorization alerts cannot be billed
They remain stuck in "Ready for Billing" until PA is fixed
Delays in PA renewal delay claims and revenue

How:

In the billing modal, if you see visits with "No Authorization" or "Exceeds Limit":
- Pause billing for that patient
- Go to Prior Authorizations module
- Update the PA (approve units, extend dates, or create new PA)
- Return to Claims Center and click "Re-Validate" button
- Alert should clear, visit becomes billable

4. Add Notes to Claims

Why:

Notes serve as communication log between billing staff
Helps with follow-ups ("Called insurance on 4/10, waiting for response")
Provides context for appeals or disputes

How:

Open claim details modal
Use the "Activity Log / Notes" text area
Save note
Notes are timestamped and attributed to your user account

5. Monitor Denial Patterns

Why:

Recurring denials from the same payer indicate systemic issues
Common denial reasons can often be prevented

How:

Weekly review of Denial Management tab
Track denial reasons (manually in notes, or use denial codes if system supports)
Identify patterns:
- Is one clinician's visits frequently denied? (documentation quality issue)
- Is one payer denying more than others? (authorization or rate issue)
- Are specific visit types denied? (incorrect HCPCS code or medical necessity issue)
Address root causes instead of resubmitting repeatedly

6. Don't Let Claims Sit in "Ready to Submit" Too Long

Why:

Delayed billing extends your cash conversion cycle
Timely filing limits (insurance may deny claims submitted more than 90 days after service date)
Increases risk of missing information (clinician may forget visit details)

How:

Set a target: Export and submit claims within 5 business days of generation
Use a weekly billing schedule:
- Monday: Generate claims for last week's visits
- Tuesday: Export 837 files and submit to clearinghouse
- Wednesday: Mark all as Submitted
Automate where possible (EDI integrations)

7. Post Payments Promptly

Why:

Accurate balance tracking
Identify payment shortfalls early (under-payments, incorrect adjustments)
Timely follow-up on remaining balances

How:

When ERA (Electronic Remittance Advice) arrives:
- Post payment within 1-2 business days
- Record exact amount, check number, and date
- Add note with ERA reference number
If payment differs from billed amount, note the reason in the payment notes (e.g., "Adjusted to contracted rate per fee schedule")

8. Use Write-Offs Judiciously

Why:

Write-offs reduce revenue (permanently)
Premature write-offs = lost recovery opportunity
Audit trail requirement

How:

Establish a write-off policy:
- Balances < $10: Write off after 60 days
- Balances $10-$100: Attempt collection for 90 days, then write off
- Balances > $100: Pursue aggressively, appeal, or send to collections
Document reason for each write-off
Get supervisor approval for write-offs > $500

Common Scenarios and Solutions

Scenario 1: Visit is Complete But Not Showing in "Ready for Billing"

Possible Causes:

Visit note is not approved yet (still in QA)
Patient has no primary payer assigned
Visit is marked as non-billable
For Medicare: OASIS not submitted or not accepted
Care order status is "Closed" or "On Hold"

Solutions:

Check QA Center: Is the visit note approved?
Check Patient Payer: Go to Patient module → Insurance tab → Verify primary payer is assigned
Check Visit: Go to Schedule Center → Find the visit → Verify isBillable = true
For Medicare: Check OASIS Submissions → Status should be ACCEPTED
Check Care Order: Care order must be "Active" or "Discharged" (not "Closed")

Scenario 2: Cannot Generate Claim Due to HIPPS Rate Missing

Error Message: "HIPPS rate not found for code 1CABA. Please configure the rate in Payer Setup for payer [Medicare] with an effective date on or before 2026-01-15, or provide a rate override."

Solution:

Option A: Configure Missing Rate
- Go to Payer Setup → Select Medicare payer
- Go to HIPPS Rates section
- Add rate for HIPPS code 1CABA
- Set effective date to Jan 1, 2026 (or earlier)
- Set rate amount (e.g., $3,200)
- Save
- Return to Claims Center and try again
Option B: Manual Override (Temporary Fix)
- In the billing modal, manually enter the rate in the "Reimbursement Rate" field
- Generate the claim
- Note: This only fixes this one claim; configure the rate in Payer Setup for future claims

Scenario 3: Claim Generated for Wrong Billing Period (Medicare)

Problem: You selected 6 visits: 4 from Period 1 (Jan 1-30) and 2 from Period 2 (Jan 31 - Feb 28). System shows error.

Solution:

Deselect the 2 Period 2 visits in the modal
Generate claim with only the 4 Period 1 visits
Close modal
Immediately click "Review & Bill" again for the same patient
Generate a second claim with the 2 Period 2 visits
Result: Two claims created (one per period, as required by Medicare)

Scenario 4: Insurance Paid Less Than Billed

Situation:

Billed: $480.00
Paid: $420.00
Difference: $60.00

Actions:

Post the $420 payment → Claim status becomes Partially Paid, balance = $60
Review the ERA (Explanation of Benefits) to understand why:
- Reason: Contractual Adjustment → $60 was adjusted to meet contracted rate (common, usually non-collectible from patient)
- Reason: Deductible → $60 is patient's responsibility (bill patient separately)
- Reason: Co-insurance → Patient owes 20% co-pay (bill patient)
- Reason: Denied Line Item → One visit was denied on the claim (investigate and appeal or write off)
If patient-responsible:
- Generate patient statement (separate workflow)
- Attempt to collect
If contractual adjustment:
- Write off the $60 (not collectible)
- Claim status remains Partially Paid with balance = $0 after write-off

Scenario 5: Need to Bill Visits from Multiple Episodes

Problem: Patient had two care orders (episodes) in the same month:

Episode 1: Jan 1 - Feb 29 (5 visits)
Episode 2 (Recert): Mar 1 - Apr 29 (3 visits)

All 8 visits are complete and ready to bill.

Solution: Critical Rule: You MUST generate separate claims for each episode.

Why: Each episode has a different HIPPS code (from different OASIS assessments). Medicare will deny a claim that mixes HIPPS codes.

Steps:

In billing modal, look at visit dates
Identify which visits belong to Episode 1 (Jan 1 - Feb 29)
Select only Episode 1 visits
Generate Claim 1
Return to Ready for Billing
Click "Review & Bill" for the same patient again
Select only Episode 2 visits (Mar 1 - Apr 29)
Generate Claim 2

Scenario 6: Claim Submitted But Insurance Says They Never Received It

Problem: You marked claim as "Submitted" 30 days ago, but insurance has no record of it.

Cause:

837 file was not actually uploaded to clearinghouse or payer portal
File upload failed (network error, format error)
Submitted to wrong payer ID

Solution:

Check if you have a confirmation from the clearinghouse (submission receipt, transaction ID)
If no confirmation exists, claim was never sent
Go to Claims Tracking → Submitted tab
Find the claim
Export a fresh 837 file
Submit to clearinghouse/payer portal (verify payer ID is correct)
Confirm submission (wait for receipt/confirmation email)
If insurance still says they don't have it after confirmed submission, escalate with clearinghouse support

Scenario 7: Want to Add More Visits to an Existing Claim

Problem: You generated a claim with 3 visits. Now 2 more visits for the same patient are complete, and you want to add them to the existing claim.

Solution: You cannot add visits to an existing claim. Claims are immutable once generated.

Workaround:

If claim is still Ready to Submit (not yet sent to insurance):
- Void the claim
- Visits return to Ready for Billing (now 5 total)
- Generate a new claim including all 5 visits
If claim is already Submitted:
- Leave the original claim as-is
- Generate a second claim with the 2 new visits
- Result: Two claims for the same patient (this is acceptable)

Scenario 8: Patient Changed Insurance Mid-Episode

Problem:

Jan 1-15: Patient had Blue Cross (5 visits completed)
Jan 16: Patient switched to Medicaid (3 visits completed after switch)

All 8 visits are ready to bill, but patient's primary payer is now Medicaid.

Solution: You must generate two separate claims:

Temporarily change patient's primary payer back to Blue Cross (or create a manual claim override - if supported)
Generate claim for the 5 visits (Jan 1-15) → Bills Blue Cross
Change patient's primary payer back to Medicaid
Generate claim for the 3 visits (Jan 16+) → Bills Medicaid

Better Approach:

In patient module, assign secondary payer (Blue Cross) in addition to primary payer (Medicaid)
When generating claims, system can intelligently bill based on effective dates of each payer
Consult with your billing specialist if this scenario occurs frequently

Troubleshooting

Issue: "Ready to Bill" Count Doesn't Match Actual Patients

Symptom: Dashboard says "Ready to bill: 5" but only 3 patients appear in the table.

Possible Causes:

Cache is stale (stats cached for 90 seconds)
Branch filter is applied (multi-branch feature)
Payer filter is hiding some patients

Solutions:

Wait 90 seconds for cache to refresh, or click Refresh button
Check branch selector (top of page) - are you viewing Head Quarter or a specific branch?
Check payer filter - change to "All Payers"

Issue: Cannot Generate Claim Due to Missing Document Approval

Error Message: "One or more provided visits are not in a billable state..." or visit doesn't appear in Ready for Billing at all.

Cause: Visit note is not approved in QA Center yet.

Solution:

Go to QA Center
Find the visit note for this visit (search by patient name or date)
Review and approve the visit note
Return to Claims Center after 2-3 minutes (give backend time to process)
Visit should now appear in Ready for Billing

Issue: Medicare Claim Shows "OASIS Not Accepted" Error

Error Message: "Cannot generate Medicare claim: OASIS submission status is '[status]'. OASIS must be submitted and accepted before billing Medicare."

Cause: OASIS for this episode is not yet submitted to CMS, or CMS rejected it.

Solution:

Go to OASIS Submissions module
Find the OASIS for this patient's care order
Check status:
- READY_TO_SUBMIT → Export XML, submit to QIES, mark as Submitted
- SUBMITTED → Wait for CMS response (usually 24-48 hours)
- REJECTED → Fix the errors CMS reported, resubmit
- PENDING_CORRECTION → Notify clinician to make corrections, re-approve in QA, resubmit
Once status is ACCEPTED, return to Claims Center
Visits should now be billable

Issue: Claim Generated But Visits Still Show in "Ready for Billing"

Symptom: You generated a claim for patient John Doe, but John Doe still appears in the Ready for Billing table with the same visits.

Possible Causes:

Claim generation failed partway through (database transaction rolled back)
Frontend didn't refresh after claim generation
Those are different visits (not the ones you billed)

Solutions:

Refresh the page (F5)
Go to Claims Tracking → Ready to Submit → Verify the claim exists
If claim doesn't exist, generation failed - check browser console for errors
If claim exists, those may be new visits completed after you generated the first claim

Issue: Voided Claim Visits Don't Reappear in "Ready for Billing"

Symptom: You voided a claim, but the visits don't show up in the Ready for Billing table.

Possible Causes:

Visits are no longer eligible (care order closed, visit note un-approved, etc.)
Frontend cache hasn't refreshed
Visits were re-billed on another claim already

Solutions:

Click Refresh button
Verify visit eligibility:
- Go to Schedule Center → Find the visits
- Check visit status = Completed and visit note status = Approved
- Check care order status = Active or Discharged
If visits were re-billed on another claim, they won't reappear (already claimed)

Permissions and Access Control

Required Permissions

Action	Required Permission	Notes
View Claims Center	`VIEW_CLAIMS`	Without this, Claims Center menu is hidden
Generate Claims	`CREATE_CLAIM`	"Review & Bill" button hidden without this permission
Mark as Submitted	`EDIT_CLAIM`	Cannot change claim status without this
Post Payments	`POST_PAYMENT`	Cannot record insurance payments without this
Void Claims	`VOID_CLAIM`	Cannot cancel claims without this
Resubmit Denied Claims	`EDIT_CLAIM`	Resubmit button hidden without this
Write Off	`WRITE_OFF_CLAIM` or `POST_PAYMENT`	Cannot write off balances without this

Role-Based Access Examples

Billing Manager (Full Access)

Permissions: All claims permissions
Can Do:
- Generate claims
- Export 837 and CMS-1500
- Mark as submitted
- Post payments
- Manage denials (resubmit, write off)
- Void claims

Billing Specialist (Limited)

Permissions: VIEW_CLAIMS, CREATE_CLAIM, EDIT_CLAIM
Can Do:
- View claims
- Generate claims
- Export claims
- Mark as submitted
Cannot Do:
- Post payments (requires manager approval)
- Void claims
- Write off claims

Finance Director (Read-Only)

Permissions: VIEW_CLAIMS only
Can Do:
- View all claims and their statuses
- Run reports on revenue and denials
- Export claim data for analysis
Cannot Do:
- Generate, edit, or void claims
- Post payments

Clinician (No Access)

Permissions: None
Cannot Access: Claims Center
Why: Clinicians focus on patient care, not billing. Their visit notes feed into claims, but they don't manage the billing process.

Integration with Other Modules

Visit Forms / Schedule Center

Link: Completed visits feed into Claims Center
Impact: Visit status and visit note approval determine billing eligibility
Flow: Clinician completes visit → QA approves note → Visit appears in Ready for Billing

QA Center

Link: Visit note must be approved before visit can be billed
Impact: QA bottlenecks delay billing
Recommendation: Prioritize QA review of visits approaching timely filing limits

OASIS Submissions (Medicare Only)

Link: OASIS acceptance is a prerequisite for Medicare billing
Impact: Cannot bill Medicare visits until OASIS status = ACCEPTED
Timeline: OASIS approval → CMS submission → 24-48 hour wait → Acceptance → Visits become billable

Prior Authorizations (Private Insurance)

Link: PA approval and remaining units determine visit eligibility
Impact: Expired/exhausted PAs block billing with MISSING_AUTH alert
Flow: PA approved → Visits generated → Visits completed → Appear in Ready for Billing (if PA still valid)

Care Orders

Link: Care order status and dates affect billing eligibility
Impact: Closed care orders block billing, discharged care orders filter post-discharge visits
Rule: Care order must be "Active" or "Discharged" to bill

Payer Setup

Link: Fee Schedules (private insurance) and HIPPS Rates (Medicare) determine claim amounts
Impact: Missing rates prevent claim generation
Recommendation: Configure all rates during payer setup, before seeing patients

Payment Posting

Link: Posted payments update claim balance and status
Impact: Claims transition from Submitted → Partially Paid → Paid based on payments received