Chapter 27: Claims Center
Chapter Overview
What You'll Learn:
- How to open Claims Center and who can use it
- The eight tabs and top KPI cards
- Visit-based billing (Ready for Billing → Review & Bill)
- Creating UNIT_BASED claims with New Claim (including billing-only agencies)
- Submitting claims electronically through Stedi vs manually
- Tracking statuses, denials, residuals, Patient AR, and clearinghouse exceptions
- Void vs Cancel
Time to Complete: 35–45 minutes
Who Should Read This: Billers, Agency Administrators, Clinical Managers who oversee revenue
Prerequisites: Payer Setup configured (Chapter 6); for full EMR visit billing, completed/approved visits and Active care orders
27.1 What Claims Center Is
The Claims Center is where you create, submit, track, and resolve insurance claims.
Path: Sidebar → Billing & revenue → Claims Center
URL: /dashboard/claims-center
Each claim asks a payer to pay for home health services and includes patient, payer, service dates, codes (HCPCS / HIPPS / service codes), and billed amounts.
Billing models (quick reference)
| Model | Typical payers | How amount is determined |
|---|---|---|
| Medicare PDGM | Medicare | HIPPS rate per 30-day payment period |
| Per-visit fee schedule | Many commercial / private | Sum of visit-type rates from the payer fee schedule |
| Unit-based | Medicaid / ODM / many MCOs | Hours or units × service-code rates |
Note: New Claim (manual / external-EVV entry) supports UNIT_BASED payers only in this release. Visit-based Ready for Billing covers PDGM and fee-schedule visit queues as well.
27.2 Access Rules
| Rule | Behavior |
|---|---|
| Permission | You need View Claim (billing:view-claim) |
| Sandbox | Claims Center is hidden and blocked. Use production (or a production billing-only agency) to bill. |
| CCN (full EMR) | Agency must have a CMS Certification Number. Without CCN you are redirected to the dashboard. |
| Billing-only agencies | May open Claims Center without CCN. Ready for Billing is hidden; default tab is New Claim. |
27.3 Screen Overview
When you open Claims Center you will see, top to bottom:
- The page title Claims Center
- A row of KPI cards (counts for Ready to bill, Submitted, Denied, Partially Paid, Follow-ups, Patient AR, Exceptions)
- A horizontal tab bar with the eight tabs listed below (billing-only agencies skip Ready for Billing)
- The active tab’s table, filters, and actions
This guide names the exact labels you see on screen — no screenshots are included (to avoid publishing patient data).
KPI cards (top)
| Card | Meaning | Click |
|---|---|---|
| Ready to bill | Patients/rows waiting in Ready for Billing | — (hidden for billing-only) |
| Submitted | Claims with status Submitted | — |
| Denied | Claims with status Denied | — |
| Partially Paid | Claims with status Partially Paid | Opens Claims Tracking → Partially Paid |
| Follow-ups | Open residual follow-up / appeal work items | Opens Follow-ups tab |
| Patient AR | Open patient-responsibility AR items | Opens Patient AR tab |
| Exceptions | Unmatched clearinghouse responses (alert style when > 0) | Opens Exceptions tab |
Eight main tabs
| Tab | Purpose |
|---|---|
| Ready for Billing | Visit queue → generate claims (full EMR only) |
| New Claim | Build a UNIT_BASED claim by service + dates of service |
| Claims Tracking | Work claims by status (Ready to Submit → Paid) |
| Denial Management | Investigate and resubmit / write off denials |
| Follow-ups | Residual appeals and follow-up work items |
| Exceptions | Clearinghouse responses that did not match a claim (PCN not found) |
| Patient AR | Collect amounts moved to the patient (Bill Patient) |
| Void | Audit list of voided claims |
Billing-only: tabs start at New Claim (no Ready for Billing).
Deep links (optional): ?tab=tracking&status=submitted&claimId=…
27.4 Visit Eligibility (Ready for Billing)
Only visits that meet all of these appear in Ready for Billing:
| Condition | Why |
|---|---|
| Visit status = Completed | Clinician finished the visit |
| Clinical document in Approved, Pending Review, or Awaiting physician signature | Ready for Billing includes these QA states — not Approved-only |
| Care order Active or Discharged | Episode is billable |
Visit is billable (isBillable) | Not marked non-billable |
| Visit not already on a claim | Prevents double-billing |
| Patient has a primary payer | Know who to bill |
Not in this queue: OASIS / Non-OASIS assessment visits (SOC, Recert, ROC, etc.) — those are not billed as routine service visits.
Additional payer rules (examples):
- Medicare PDGM: HIPPS / period rules; may show Bill in N day(s) until the 30-day period is billable
- Payers requiring PA: Authorization must allow the visits (missing or over-limit blocks billing)
- Fee schedule / service codes: Rates must exist or the UI shows rate-missing warnings
27.5 Ready for Billing (full EMR)
Table columns
Patient name · Payer · Payment period · Unbilled visits · Estimated amount · Last billed · Actions
Filters
- Payer (All Payers)
- Date range (All Time / Last 7 Days / Last 30 Days / This Month)
- Refresh
Generate a claim
- Open Ready for Billing.
- Optionally filter by payer or date range.
- Click Review & Bill (or wait if the button shows Bill in N day(s) for a future Medicare period).
- In Bill Patient: {name}, select visits, fix missing rates / auth issues, confirm Medicare HIPPS if shown.
- Click Generate Claim ….
- The claim appears under Claims Tracking → Ready to Submit.
Row menu (⋮): Mark Visit as Non-Billable for individual visits that should not be billed.
Watch for:
- Billing paused on the payer
- Auth badges: missing authorization or exceeds limit → cannot bill until fixed
27.6 New Claim (UNIT_BASED)
Use New Claim when you need to enter a claim for a UNIT_BASED payer without (or outside) the visit queue — for example external EVV (Sandata) visits, or billing-only agencies.
Header copy (product)
Select a service once, then add each date of service with hours or units. Each date becomes its own claim line. UNIT_BASED payers only.
Billing Mode (full EMR only)
| Mode | Meaning |
|---|---|
| Care Order Based | Requires an active plan of care / care order context |
| Standalone | No POC required |
Billing-only agencies always use Standalone (toggle hidden).
Billing Source (required)
| Dropdown label | Chip on claim tables |
|---|---|
| External EVV — Sandata | Sandata |
| External EVV — Other | External EVV |
| Manual Non-EVV | Manual Non-EVV |
| Betasky EVV (if Alt-EVV enabled) | Betasky EVV |
Create steps
- Open New Claim.
- Choose Billing Mode (if shown).
- Select patient, UNIT_BASED payer, physician / care order (as required), PA and diagnosis as needed.
- Choose Billing Source.
- If Billing Source is External EVV — Sandata: use Available Sandata EVV Visits → Use Visit for each Verified visit (import first via Chapter 35: Sandata Migration). Only Ready to claim visits appear.
- Otherwise pick HCPCS / Service code, then add each date of service with hours or units (and modifiers / place of service as needed).
- Review the preview → Create Claim ($…) .
- You are taken to Claims Tracking → Ready to Submit.
27.7 Claims Tracking
Sub-tabs
| Sub-tab | Claim status |
|---|---|
| Ready to Submit | Ready to Submit |
| Submitted | Submitted |
| Partially Paid | Partially Paid |
| Paid | Paid |
Columns
Patient name · Payer · Claim # · Service dates · Billed amount · Balance due · PR / Path · Status · Actions
Useful chips under a claim:
- Electronic or Manual (how it was submitted)
- Billing source: Sandata, External EVV, Manual Non-EVV, Betasky EVV, Visit, Same-Payer Rebill, Secondary COB
- Clearinghouse acknowledgment (automatic 277CA) — not the same as Check Status
- In Draft Batch — claim is locked inside a Payment Posting draft remittance
Filters: Payer: All, Search Patient Name, Refresh.
27.8 Submit a Claim (Ready to Submit)
From Claims Tracking → Ready to Submit, open the row ⋮ menu.
Option A — Download 837 (file export)
- Download 837 → Download 837 File.
- Choose Download 837P (Professional) or Download 837I (Institutional).
- Upload the file to the payer portal yourself if you are not using Stedi.
- Continue to mark submitted if prompted, or use Submit Claim → Manual Submission.
Option B — Submit Claim modal
⋮ → Submit Claim opens Submit Claim:
- Pre-submission Validation (checklist, 837P/837I chip, EDI preview tips).
- Choose Submission Method:
| Choice | Label | What happens |
|---|---|---|
| Electronic | Submit Electronically | Send through the Stedi clearinghouse. The UI shows Test Mode (ISA15=T) or Production Mode (ISA15=P) — this mode is set by the server (sandbox / dry-run / production config). You confirm the submit; you do not toggle Test↔Live yourself. Optional coverage verification. Attachments may go with the 837 / 275 after accept. |
| Manual | Manual Submission | You already uploaded the 837 to the payer portal. Confirm the checkbox → Mark as Submitted. |
Electronic confirmation buttons include Submit Test Claim or Submit to Live Payers (label matches the server mode above).
After electronic vs manual
| Electronic (Stedi) | Manual | |
|---|---|---|
| Chip | Electronic | Manual |
| Status updates | From Stedi (999 / 277CA / 835) — not manual edits | Biller can Post Payment / Mark as Denied |
| Check Status | Real-time Claim Status Inquiry (276/277) | Not the electronic inquiry path |
| Void | May Send electronic void (frequency 8) through Stedi, or void locally | Local void |
Important: For electronic claims, do not expect to manually Post Payment or Mark as Denied from Claims Tracking — those actions are disabled. Payments and denials arrive through clearinghouse responses (and Payment Posting / Exceptions when matching fails).
27.9 Tracking Actions by Status
Ready to Submit (⋮)
- View Details · View PA (if linked)
- Download 837 · Submit Claim
- Void / Cancel → choose:
- Void — keep a record (claim moves to Void tab)
- Cancel — remove completely (no Void audit row; visits can return to Ready for Billing when applicable)
Submitted (⋮)
- View Details · View PA
- Electronic: Check Status; Post Payment / Mark as Denied disabled
- Manual: Post Payment, Mark as Denied, Void Claim
- Primary claims: Recycle (new claim from template with shifted dates)
Partially Paid (⋮)
Residual options (when balance remains):
| Action | Result |
|---|---|
| Bill Patient | Moves residual to Patient AR |
| Bill Secondary | Creates a secondary COB claim |
| Rebill Same Payer | Creates a same-payer rebill child claim |
| Write Off Residual | Writes off remaining claim balance |
| Appeal / Follow-up | Opens a work item on Follow-ups |
Also: Void Claim, Recycle (primary), electronic locks as above.
Paid (⋮)
- View Details, electronic Check Status, Recycle (primary)
27.10 Denial Management
Purpose: Review, investigate, and resolve denied claims.
Columns include Reject / denial reason, amounts, status, and actions.
⋮ menu:
- View Details · View PA
- Resubmit → Resubmit Claim
- Prepare only (Ready to Submit) → unlock for resubmit
- Resubmit as original (frequency 1) → continue to electronic submit
- Electronic replacement (frequency 7) when an ICN/PCCN is available (not for Medicare) → enter Payer claim control number (ICN / PCCN)
- Write Off — write off the denied balance when unrecoverable
27.11 Follow-ups
On-page title: Follow-ups & Appeals
Work residual items created from Partially Paid (or related) actions.
Filters: Type (All open / Appeals / Follow-ups); Due (All dates / Due today or earlier / Overdue).
⋮ menu:
- Resolve residual… → Bill patient / Bill secondary / Rebill same payer / Write off → Confirm resolve
- Update status / date (follow-up date; appeal status: Open, Submitted, Pending payer, Won, Lost, Withdrawn)
- Close (won / withdrawn) — outcomes include Won / Withdrawn / Cancelled
27.12 Exceptions (Clearinghouse)
Purpose: Payments or status responses from the clearinghouse that could not be matched to a Betasky claim (for example PCN not found).
Summary cards: OPEN · 835 ERA · 277CA · PAYMENT AT RISK
Filters: Search PCN / check # / payer; status Open / Resolved / Ignored / All; source All / 835 ERA / 277CA / 999.
What creates an exception today: unmatched 835 ERA and 277CA responses (typically PCN not found). A 999 source filter exists in the UI; unmatched 999 rejects currently update matched claims to Denied when possible and are not always written as exception rows.
Actions:
- Link to an existing claim — attach the exception to the correct claim
- Ignore this exception — close without linking
Exceptions are scoped to your agency. Unmatched responses for another agency’s claim numbers will not appear in your list.
Empty state: All clear — no unmatched clearinghouse responses in this view.
27.13 Patient AR
Purpose: Money moved off insurance claims via Bill Patient. Collect, age, assign, and track statements here.
Aging cards (clickable): 0–30 days · 31–60 · 61–90 · 90+
Filters: Status (Open / Partial / Paid / Written off / All); Aging buckets.
⋮ menu: Post payment · Write off · Assign · Mark statement sent
27.14 Void Tab
Lists claims with status Void (kept for audit). Claims reach this tab when you choose Void (not Cancel).
Electronic voids may also send a frequency-8 void through Stedi when you choose that option.
27.15 Billing-Only Agencies
| Area | Full EMR | Billing-only |
|---|---|---|
| Ready for Billing + Ready to bill KPI | Yes | Hidden |
| Default tab | Ready for Billing | New Claim |
| Billing Mode | Care Order / Standalone | Always Standalone |
| CCN required to open Claims Center | Yes | No |
| Typical claim path | Review & Bill from visits | New Claim + Billing Source (e.g. Sandata) |
Billing-only agencies still use Claims Tracking, Denials, Follow-ups, Exceptions, Patient AR, and Void the same way after a claim exists.
27.16 Related Modules (not inside this page)
| Module | Relationship |
|---|---|
| Payment Posting | Build/post remittance batches; auto 835 ingest may create payments and lock claims In Draft Batch |
| EVV Center | Alt-EVV / Sandata sync — Chapter 28 |
| Sandata Migration | Import Sandata Visits Claims Verification Status → claimable visits for External EVV — Sandata — Chapter 35 |
| Payer Setup | Enrollment, electronic payer IDs, service codes / fee schedules / HIPPS |
| Prior Authorizations | Units/hours that allow Ready for Billing |
27.17 Common Mistakes
- Expecting Claims Center in sandbox — it is blocked.
- Trying to manually post/deny an Electronic claim — wait for Stedi / ERA (or use Exceptions if unmatched).
- Using Cancel when you needed an audit trail — use Void instead.
- Creating New Claim for a non–UNIT_BASED payer — not supported; use Ready for Billing for visit-based PDGM / fee-schedule queues.
- Ignoring Exceptions — unmatched 835s mean payment may not hit the claim until you link the PCN.
- Thinking Ready for Billing requires Approved-only notes — Pending Review and Awaiting physician signature visits can also appear when other eligibility rules pass.
- Expecting to toggle Stedi Test/Live in the submit modal — mode is automatic; confirm and submit.
27.18 Quick Checklist
- Production agency (not sandbox); CCN present unless billing-only
- Payers enrolled / rates or service codes configured
- Full EMR: Ready for Billing → Review & Bill → Ready to Submit
Billing-only: New Claim → Create Claim → Ready to Submit - Submit electronically (Stedi) or mark manual after portal upload
- Monitor Submitted / Partially Paid / Denied
- Work Follow-ups, Patient AR, and Exceptions until clear
Next: Chapter 28: EVV Center · Chapter 29: Payment Posting — remittance batches and ERA payments.