Home Care Medicaid and Medicare Billing Software

Claims are generated only from EVV-verified visit records -- a visit without a verified EVV record cannot produce a claim until the exception is resolved. Visit duration from the EVV check-in and check-out is converted to billable units by the payer's rate table, with rounding rules applied per payer specification. Visits with unresolved EVV exceptions are held in a pre-submission review queue visible to the billing team, with the exception type displayed so the coordinator or caregiver can resolve it without the billing team needing to investigate manually. Claim generation can be triggered automatically when a visit is verified or run as a manual batch by the billing team at the end of a billing period.

Each client has an authorisation record per payer covering the approved hours, service type, and validity period for that authorisation. Authorised hours are consumed as visits are verified and billed -- the running balance updates with each verified visit so the remaining authorised hours are always current. Remaining hours are visible on the client record and in the scheduling view when a new visit is being assigned, so coordinators can see whether the client has hours available before the visit is scheduled rather than after the claim is rejected. An alert fires when a client is within a configurable threshold of exhausting their authorised hours, giving the agency time to submit a renewal request before the authorisation runs out. Prior authorisation renewal requests are tracked with submission date, payer response, and new authorisation details recorded when approved.

Rate tables are configured per payer: Medicaid fee-for-service, Medicaid managed care organisations by plan, Medicare, long-term care insurance, and private pay. Service codes and rates are managed per payer with effective date tracking so rate updates are applied from the correct date without requiring manual correction of past claims. Payer-specific billing unit definitions are configured at the payer level -- some payers bill in 15-minute increments, others at a daily rate or a per-visit rate -- and the claim generation logic applies the correct unit definition per payer without the billing team selecting it manually for each claim. When a contracted rate is updated, an alert notifies the billing team before the new rate takes effect so rate changes are not missed until a claim is paid at the wrong amount.

Electronic claim submission to Medicaid and Medicare via 837P transaction or state-specific billing portal, configured for the submission method required by each payer. Each claim has a tracked status -- accepted, pending, rejected, and paid -- updated as payer responses are received. A rejection alert includes the denial reason code and the resubmission guidance relevant to that code so the billing team knows immediately what action is required. Claims are managed in batches with a submission log per batch: submission date, number of claims, total billed amount, and confirmation numbers from the payer so the billing team can reconcile what was sent against what was acknowledged.

835 remittance files from each payer are processed automatically with payment and adjustment amounts posted to the corresponding claims. Denial reason analysis groups denied claims by denial code into a rework queue so the billing team can see where the same denial is recurring across multiple claims rather than working each denial individually. For clients with dual eligibility -- covered by both Medicaid and Medicare -- secondary billing is generated after the primary payment posts, with the client liability calculated from the combined primary and secondary payment. Payment reconciliation reports match posted payments against deposit records so the billing manager can confirm the bank deposit matches the remittance totals.

Accounts receivable by payer with aging buckets -- current, 30 days, 60 days, 90 days, and over 90 -- so the billing team can see where collections are running behind and which payers are slow to pay. Denial rate by payer and by service code over a rolling period identifies systemic billing problems rather than one-off errors. Collection rate by payer shows what percentage of billed amounts are being collected from each payer over time, which informs contract renegotiation and payer mix decisions. Revenue per authorised hour measures how efficiently the agency is using its prior authorisation capacity. Cash flow forecast based on claims submitted and the average payment timeline per payer gives the finance team a forward view of receivable collections.