Medicaid Claims Billing lets communities bill Medicaid payers by electronic claim instead of by invoice. ALIS tracks each resident's billable service days, generates the 837I claim file, and records the payer's remittance against those claims. This guide gives an overview of the enablement requirements and the claims billing cycle.
About Medicaid Claims Billing
Claims-billed payer types work differently from invoice-based payer types. ALIS adds each resident's service days to the Billing Queue every night and posts that revenue to the general ledger as it accrues, before a claim is sent.
When you're ready to bill, you export the queued days as a claim batch and upload the file to your payer or clearinghouse. When the payer pays, you upload its remittance (835) to mark the claims paid and clear the receivable.
Note: ALIS does not send claim files or receive remittances directly. You transfer files through your payer's portal or your clearinghouse.
Enablement Requirements
Medicaid Billing is behind an entitlement and requires the ALIS team to enable it for your company. To have it enabled, contact your Account Manager or the ALIS Customer Support Team.
Before your first export, confirm the following are in place:
- Medicaid Billing Entitlement & Security Role Permissions: Enabled for your company by the ALIS team.
- Payer Enrollment: The payer's companion guide or clearinghouse enrollment, which supplies your Payer ID, Receiver ID, Submitter ID, and required codes.
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Payer Type: A payer type that uses the Claims generating method, with Claim Submission Details completed on its Billing Program and a Leave billing rule that matches your payer’s requirements:
- Exclude only days away the whole day (default): departure and return days are billed.
- Exclude every day a leave touches: departure and return days are not billed.
- Billing items: A procedure code and any claim modifiers on each billed service, plus a revenue GL account.
- GL Accounts: An Accounts Receivable and a Primary Deposit account mapped on the claims payer type.
- GL Integration (if you export your GL to an accounting system): Enabled for your company. See How to Enable Your GL Integration.
- Community Details: The community address and a valid 10-digit billing contact phone number.
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Resident Profile Information & Billing:
- Basic Information (Birth Date, Sex at Birth, Medical Record #)
- An active, primary Insurance Information record with a Subscriber #
- Physician contact with an NPI
- A claims-specific Recurring Charge linked to the resident’s Medicaid insurance
For full setup steps, see How to Set Up Medicaid Claims Billing.
Access Medicaid Claims Billing
Once Medicaid Billing is turned on and configured, claims work happens on the Medicaid Billing page:
- Enhanced Navigation (sidebar): Billing → Resident Billing → Medicaid Billing
- Legacy Navigation (top menu): Billing → Medicaid Billing
Pictured: Enhanced Navigation
The Claims Billing Cycle
Use this table to find the right guide for where you are in the claims cycle. Setup happens once per community. Steps 4 through 9 repeat every billing cycle. Steps marked (outside ALIS) happen in your clearinghouse or the payer’s portal.
| Step | Stage | When to use it | Guide |
|---|---|---|---|
| 1 | Set up Claims Billing | Once per community, or when payer values, procedure codes, or GL accounts change | How to Set Up Medicaid Claims Billing |
| 2 | Add a Resident to Claims Billing | When a resident starts on Medicaid or the waiver program, or their insurance or physician changes | How to Set Up Medicaid Claims Billing, Steps 6–7 |
| 3 | Hold and Release Claims (as needed) | When waiver paperwork or an authorization is pending, and when it’s approved | How to Hold and Release Medicaid Claims |
| 4 | Service Days Accrue | Automatic each night. No action needed. | How Medicaid Claims Post to the General Ledger |
| 5 | Generate and Export Claims | Each billing cycle, once service days are in the Billing Queue | How to Generate Claims and Correct Rejected or Denied Claims |
| 6 | Submit the Claim File (outside ALIS) | Right after export | Your clearinghouse or payer portal |
| 7 | Correct a Rejected Claim | When the clearinghouse or payer portal rejects a claim before payment | How to Generate Claims and Correct Rejected or Denied Claims |
| 8 | Post a payment | When the payer’s 835 (ERA) arrives | How to Post a Clean Medicaid Payment (836/ERA) |
| 9 | Correct a Denied Claim | When a saved 835 shows a claim as Denied | How to Generate Claims and Correct Rejected or Denied Claims |
| 10 | Check a Claim’s Status | Any time after export, for one resident | How to Check a Resident’s Medicaid Claim Status |
| 11 | Review Claims Reports | Month end, audits, or follow-up across all residents | Medicaid Claims Reports |
Key Areas
Claims work happens in two places: the Medicaid Billing page for the whole community, and each resident’s profile.
Billing Queue tab
Unbilled service days waiting to be exported, with filters, Sync now, and Export Claims.
Export tab
Each exported batch, with its billed and paid amounts and the remittance (835) linked to it.
Audit tab
A record of exports, removals, saved remittances, voids, and skipped claims.
Reconcile Remittance
Where you review an uploaded 835 against your claims before saving it.
Resident Claims tab
On the resident’s profile > Billing > under Invoices & Claims: each claim’s status, billed and paid amounts, and linked remittance.
Medicaid Claims Billing Glossary
For key terms in the claims process, where each value comes from, and where you enter it, see Medicaid Claims Billing Glossary.