Claim FAQs

AlayaCareAlex

Here is a list of all current FAQs related to Claims. If issue is not resolved after going through the steps in this guide, please search through Zendesk articles or have your super user submit a Zendesk ticket.

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1. Why will visits not generate into a Claim? 
2. Why am I receiving an error message in claim generation stating ‘Visits were scheduled before the bill code effective date for the following bill codes: xxxxx’? 
3. Why am I getting an error message in claim generation stating ‘The same date of service cannot appear on more than one claim. The following claims should be voided so that all visits on that same date of service fall on the same claim: xxxxx’? 
4. How do I void a claim and have the attached visits NOT generate in a new claim? 
5. Why is my claim showing as Paid status but with $0.00 payment?
6. How do I set a claim to balance to zero for overpayments due to bill rate increase on payor side? 
7. Why are the claim approved units not matching units sent? 
8. Why are Approved units not populating? 
9. Why are Approved Units populating as 1 instead of the approved billable quantity? 
10. How can I re-generate a claim for visits when the payor on the service was changed? 

1. Why will visits not generate into a Claim? 

There are a few reasons why visits will not generate into a claim.  Some troubleshooting and resolution steps have been outlined below to help you determine what is blocking the visits and how to generate the visits into a claim. 

Check the following items: 

• Make sure the client’s service on the visit is correctly configured for the Payor Methodology as Electronic Billing  
  • Navigate to the client’s service page 
  • Edit the service to see what is configured for Funder Methodology 

• Confirm that all visits on the same date of service (DOS) with the same payor and authorization number are approved, cancelled or on-hold. If any of these visits are unapproved it will block claim generation for that day’s visits. 
• Vacant visits need to be cancelled or on-hold: if a vacant visit exists on the same day as other visits with the same payor and authorization number, the vacant visit needs to have a non-billable cancel code on it or set to on-hold, then claims can be generated.  
• To find any same day visits that may be blocking billing you can use the Scheduled Visits function to find all visits on that date: 
  • Navigate to Schedules > Scheduled Visits 
  • Filter by the client's name, service code (if applicable) and use the visit date as the start and end date filter 
  • Click the Search Visits button and a listing of visits will populate 
  • Any visits that are not approved, cancelled or on-hold will need to have the status changed to either approved, cancelled, or on-hold by clicking on the Visit ID link to bring up the visit details then choosing the required status (for EVV (Electronic Visit Verification) use Visit Verification if visit is to be approved) 

• Verify bill code is not set to be excluded from billing:  

• Verify the bill code on the visit has an effective date set to before the first visit to be billed:

• Verify the billed quantity is approved for a value greater than zero, you can find this information either in Visit Verification when reviewing a visit or in the visit details when looking at the visit revisions under the Revision button on the right-hand side of the visit detail page. 

Using Visit Verification:

Using Visit Details:

• Once corrections are made to the service/visit status/bill code can generate claims as per your normal claim generation practices to pick up the visits for that day. 
• It is recommended to run the Unbilled Visits Report accounting export each billing cycle to find all approved unbilled visits. Please note this export does not report unapproved visits. 

• We also recommend creating a DE (Data Exploration) 2.0 report to find all unapproved and vacant visits and run the report prior to each billing cycle to ensure all visits within a date range are approved, cancelled, or on-hold.  (See mock up below as an example. Note that any employee name that populates as zero (0) are vacant visits). 

2. Why am I receiving an error message in claim generation stating ‘Visits were scheduled before the bill code effective date for the following bill codes: xxxxx’? 

This error means there are unbilled visits prior to the bill code effective date that are attached to this bill code and are blocking claim generation. Some troubleshooting and resolution steps have been outlined below to help resolve this issue. 

Check the following items: 

• Verify this bill code has an effective date that is set to prior to the first visit to be billed. If the bill code effective date is not set to a date prior to the first unbilled, approved visit for the same payor and authorization #, it will block claim generation. 
  • Navigate to Accounting>Accounting Settings>Bill Code and filter for this bill code 
  • Click the Edit button to view bill code configuration 
  • If effective date is prior to the first unbilled visit, either edit the date to the first visit date OR set the visit to Cancelled or On-hold if you do not wish to visit to be billed 

• Confirm that all visits prior to the visit cut-off date in claim generation with the same payor, bill code and authorization # are either cancelled or on-hold. This includes any vacant visits. If any of these past visits are not cancelled or not on-hold, it will block claim generation. 
• Confirm that all visits on the same date of service (DOS) with the same payor and authorization number are approved, cancelled or on-hold. If any of these visits are unapproved it will block claim generation for that day’s visits. 
• To find any prior visits that may be blocking billing you can use the Scheduled Visits function to find the status of prior visits: 
  • Navigate to Schedules > Scheduled Visits 
  • Filter by the client's name, service code (if applicable) and use a date range that encompasses a broad date range. Recommend using a start date of a least one year prior (there may be past visits that were not cancelled, or not on-hold that are attached to this bill code) and use the end date that is the same as the visit cut-off date when generating claims  
  • If the status of prior visits needs to be changed you can change the status by clicking on the Visit ID link to bring up the visit’s details, then choose the required status (for EVV (Electronic Visit Verification) use Visit Verification if visit is to be approved) 

• Once corrections are made to the visit status or bill code you can generate claims as per your normal claim generation practices to pick up the visits. 
• It is recommended to run the Unbilled Visits Report accounting export each billing cycle to find all approved unbilled visits. Please note this export does not report unapproved visits. 

3. Why am I getting an error message in claim generation stating ‘The same date of service cannot appear on more than one claim. The following claims should be voided so that all visits on that same date of service fall on the same claim: xxxxx’? 

This error means there are unbilled visits on the same date(s) with the same authorization # and payor as the service dates on the listed claims that have not been cancelled or put on hold and a prior claim already contains billed visits for the same date(s).  All same day visits with same payor and authorization # can only be billed on one claim and a new claim cannot be generated for these additional visits. Prior claim(s) needs to be voided and a new claim(s) generated to pick up ALL same day visits once corrections are made. 

Check the following items: 

• Confirm that all visits on the same date of service (DOS) with the same payor and authorization number are approved, cancelled or on-hold. 
• Vacant visits need to be cancelled or on-hold: if a vacant visit exists on the same day as other visits with the same payor and authorization number, the vacant visit needs to have a non-billable cancel code on it or set to on-hold, then claims can be generated. 
• To find any same day visits that may be blocking billing you can use the Scheduled Visits function to find any visits that are not approved, not cancelled or not on-hold: 
  • Navigate to Schedules > Scheduled Visits 
  • Filter by the client's name, service code (if applicable) and visit dates that appear in the claims to be void 
  • Any visits that are not approved, cancelled or on-hold will need to have the status changed to one of these three statuses by clicking on the Visit ID link to bring up the visit details then choosing the required status (for EVV use Visit Verification if visit is to be approved) 

• Once corrections are made to the visit status you will need to void the claims listed in the error message and generate claims again to pick up the all the expected visits on that DOS. 
• It is recommended to run the Unbilled Visits Report accounting export each billing cycle to find all approved unbilled visits. Please note this export does not report unapproved visits. 

4. How do I void a claim and have the attached visits NOT generate in a new claim? 

• Void the claim. 
• Prior to next claim generation you can either add a non-billable cancelled code to the visit if you wish to cancel the visit or you can edit the bill override to zero (0) in the approval tab – VERY IMPORTANT TO DO THIS STEP PRIOR TO NEXT CLAIM GENERATION OR THE VISIT(S) WILL BE PULLED INTO A NEW CLAIM AGAIN. 

5. Why is my claim showing as Paid status but with $0.00 payment? 

• This means the 835 payment file was transmitted to ACC with a $0 payment and no denial code. 
• AlayaCare sets the status to paid because without a denial code we do not know it is denied, it appears as if the claim is paid with a zero value. 
• In the Claim Events you will see an event named ‘Claim payment $0.00’. 

• To resolve the denial, you will need to look at your EOB (Explanation of Benefits) to find the rationale for why the claim was denied and make necessary corrections to the claim, payor, client, and/or linked visit(s). 
  • If corrections are needed on the claim, you can Revise the claim send the revised information 
  • If corrections are needed for payor, client, or linked visits, you will need to void the claim, make corrections and generate claims again to pick up new information 

6. How do I set a claim to balance to zero for overpayments due to bill rate increase on payor side? 

• Scenario - Payor has retroactively paid claims with a higher bill rate but increase not reflected in the claim due to payor not advising, resulting in payments of higher values now reflecting as an overpayment. 
• You will need to revise the claim’s bill value (Revise claim to reconcile with clearinghouse) on service lines to match the amount paid. No need to resend the claim, only revising to match the higher payment. 

7. Why are the claim approved units not matching units sent? 

There are instances where a bill code is linked to visits, then the bill code was disabled but replacement bill code was not added to the service code prior to claim generation. This results in mismatched units. 

The steps below will help you find the bill code and resolve this issue: 

• Navigate to Accounting>Accounting Settings >Bill Codes. 
• Change status filter to ‘Disabled’. 

• Filter for this bill code, you should see this bill code is listed in the Disabled listing. 
  • If this bill code is not disabled, please create a Zendesk ticket for our support agents to investigate. 
  • If this bill code is disabled, please continue with the steps below. 
• You will need to change the code name and description of the bill code to put DNU in front of the description (this is to allow you to easily identify if this bill code is attached to the service code and visit). 

• From there, navigate to Service Codes and search for the service code linked to the visit. 
• Use the drop-down arrow next to the Edit button and choose ‘Edit billing detail’. 

• You should see this bill code with DNU as the precursor, this bill code needs to be replaced with the correct enabled bill code by clicking on the Edit button for that payor in the service code and change the bill code to the correct one. 

• Click the Confirm button then the Save button to save the change. 
• Navigate to the affected claim(s) and void them, generate claims again as per your normal practice in order to pick up the replacement bill code. 

8. Why are Approved units not populating? 

There are instances where the approved units will not populate into a claim due to the bill rate being set to ‘per rate’. The bill rate for claims needs to be either ‘per hour’ or ‘per visit’. 

The steps below will help you find the bill code and resolve this issue: 

• Navigate to Accounting>Accounting Settings>Billing Codes 
• Filter for the bill code linked to the claim 
• On the main Bill Codes page you will see how the effective rate is configured 

• If the bill code is configured for 'per rate', you will need to disable this bill code and create a new bill code (as per your normal practice) with the units as either ‘per hour’ or ‘per visit’.  The units on a bill code cannot be edited. 
  • It is recommended to add the precursor DNU to the disabled code 
• The visit’s service code will need to have the disabled bill code replaced with the new bill code  
• If a client has any custom bill codes assigned, the new bill code will need to be added and the custom rate added 
• Claim(s) will need to void and generated again to pick up the new bill code 

9. Why are Approved Units populating as 1 instead of the approved billable quantity? 

There are instances where the bill code is incorrectly set to ‘per visit’ instead of ‘per hour’ which causes the claim to generate with approved units of one (1) instead of the approved billed quantity on the visit. 

The steps below will help you find the bill code and resolve this issue: 

• Navigate to Accounting>Accounting Settings>Billing Codes 
• Filter for the bill code linked to the claim 
• On the main Bill Codes page you will see how the effective rate is configured 

• If the bill code is configured for 'per visit', you will need to disable this bill code and create a new bill code (as per your normal practice) with the units as ‘per hour’.  The units on a bill code cannot be edited. 
  • It is recommended to add the precursor DNU to the disabled code.  
• The visit’s service code will need to have the disabled bill code replaced with the new bill code  
• If a client has any custom bill codes assigned, the new bill code will need to be added and the custom rate added 
• Claim(s) will need to void and generated again to pick up the new bill code

10. How can I re-generate a claim for visits when the payor on the service was changed? 

There are instances where a service was configured for the incorrect payor and a claim was generated.  The payor was changed on the service and billing needs to be completed for the new payor. 

The steps below will guide you with resolving this issue: 

• Navigate to the claim(s) that were generated with the incorrect payor and void these claim(s) as per your normal claim practices 
  • Please note that a claim can only be void when in the status of Draft, Prepared, Paid, Denied or Rejected; if the claim is in Acknowledged, Accepted or Sent status the best practice is to wait for payment/rejection from payor first and there may be a disconnect when the payment or rejection is transmitted to ACC 
• Change the payor on the service using the following steps: 
  • Navigate to the client’s profile  
  • Click on Care Management>Services 
  • Find the service linked to the visit(s) and click the ‘Edit Service’ button

• Edit the Payor to the new payor 

• Click ‘Save’ to save the changes 
• Navigate to Claims and generate claim(s) for the new payor 

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