Communities that bill Medicaid by claim need several parts of ALIS set up before they can export claims: the payer type, its Billing Program, billing items, community details, and each resident's profile and recurring charge. ALIS writes these values onto every 837I claim file, and they must match what the payer expects, or the clearinghouse or payer may reject the claim.
Enable Medicaid Billing
Medicaid Billing is behind and 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.
Once enabled, configuration begins in your community's Billing Settings.
Before You Begin
- Payer values: Gather the payer's values from its companion guide or your clearinghouse enrollment. You'll need the Payer Name, Payer ID (EDI), Receiver ID, Submitter ID, Facility Type Code, Provider Taxonomy Code, procedure codes, and modifiers.
- Community values: Have the community's Billing NPI and Tax ID ready.
- Switching from another billing system: Have the interchange and batch numbers from the last claim file your old system submitted. You will use these in Step 2.
For more information on key terms, see Medicaid Claims Billing Glossary.
Setup Steps Overview
Complete these steps in order. Each is described in more detail below.
Payer Type: create the payer type with the Claims generating method.
Billing Program: complete Claim Submission Details for the payer type.
Billing Items: set the item type, procedure code, unit, and modifiers.
Community Details: confirm the address and billing contact phone.
Resident profile: add insurance, birth date, sex, medical record number, and attending physician.
Recurring charge: add the claims charge, linked to the resident's insurance.
Step 1: Create a Claims Payer Type
The generating method tells ALIS to bill this payer type by claim instead of by invoice.
- Go to Billing Settings > General tab.
- Add a new payer type Name.
- Under Generating Method, select Claims.
- (Optional) Type a description for internal use.
- Click Save. This creates a new tab at the top of the Billing Settings page.
Important: You cannot change the Generating Method after you have saved the payer type. To switch between invoices and claims, you need to create a new payer type.
Step 2: Complete Claim Submission Details on the Billing Program
The Billing Program holds the payer and provider identifiers written to every claim.
- Scroll to the top of Billing Settings > select the tab for the claims payer type (for example, Medi-Cal).
- In the left-hand list, select Billing Program.
- Click Edit (if on the existing program), or click Enable Billing Program to create one.
- Complete the Claim Submission Details fields. All fields are required except the two starting numbers.
- Click Save (or Enable Billing Program).
| Enable Billing Program Field | What to enter |
|---|---|
| Payer Name | The payer's name as it should appear on the claim. |
| Payer ID (EDI) | The payer's electronic ID. |
| Billing NPI | The community's billing National Provider Identifier. |
| Receiver ID | The ID of the clearinghouse or payer receiving the file. |
| Tax ID | The community's tax ID. |
| Submitter ID | The ID the payer assigned to this community as the submitter. Each community has its own, even within one company. |
| Facility Type Code | A one- or two-character code identifying the type of facility. Medi-Cal uses 33. Other payers may use a different code. |
| Provider Taxonomy Code | The NUCC taxonomy code for the billing provider. 310400000X identifies an assisted living facility. More specific codes exist by specialization, so check the payer's companion guide. |
| *Starting Interchange Number | Only needed when moving from another billing system. Otherwise, leave it blank. |
| *Starting Batch Number | Only needed when moving from another billing system. Otherwise, leave it blank. |
Some existing Billing Programs already contain Facility Type Code 33 and Provider Taxonomy Code 310400000X. New Billing Programs start with both fields blank. Confirm both values with each payer, especially for non-Medi-Cal programs and memory care communities with a specialized taxonomy.
*Starting Interchange and Batch Numbers
Every claim file carries an interchange number and a batch number. The payer can reject a file that reuses a number it already received from your community. If the community previously submitted claims from another system, enter that system's last numbers so ALIS continues above them.
- Use the numbers from the last file the old system submitted. Do not estimate them. The interchange number can advance by thousands a day.
- A starting number is a floor, not a reset. ALIS uses the next number above it. If ALIS has already passed it, it has no effect.
- Enter up to 9 digits.
- Enter them before the community's first export. They only affect files generated after you save them.
Step 3: Set Up Claims Billing Items
Each service you bill on claims needs claims fields on its billing item.
- In Billing Settings, select the claims payer type tab (for example, Medi-Cal).
- In the left-hand list, select Revenue.
- Click + Add Billing Item, or open an existing billing item to edit it.
- Complete the billing item fields, including the Claim Configuration fields below.
- Click Save.
| Billing Item Field | What to enter |
|---|---|
| Item Type | Service Based for a per-day service (for example, T2031 Assisted Living Services). Time Based for a service billed in time units (for example, T2017 Residential Habilitation, per 15 minutes). |
| Procedure Code | The HCPCS code the payer expects, such as T2031. |
| Claim Modifiers (4 max) | Up to four modifiers, such as the resident’s care tier (for example, U1). ALIS writes them on each service line. |
| Billing Unit Type | Time Based items only. The amount of time one unit represents, as a number and a unit (for example, 15 Minute). |
Tips:
One procedure code can cover several levels of the same service. For example, Medi-Cal’s Assisted Living Waiver uses T2031 for every tier, with modifiers U1 to U5 identifying the tier. Create a separate billing item for each code and modifier combination.
Bulk Add/Edit Billing Items, Download Templates, and Export to Excel include the item type, modifier, and billing unit type columns.
Step 4: Confirm the Community's Details
The claim uses the community’s address and billing contact phone number from the Community Details page.
- Open the Community Details page. [CONFIRM: Enhanced and Legacy Navigation paths]
- Under Building Information, confirm the community’s Street Address, City, State, and ZIP Code.
- Under Billing Information, enter the billing contact’s Phone #.
- Click Save.
How ALIS formats these values on the claim:
- Phone number: ALIS uses the Billing Information Phone #. If blank, ALIS uses the Building Information Phone #.
- Phone format: The number must be a valid 10-digit U.S. phone number. ALIS writes it as digits only and drops a leading country code (for example, 1 (559) 555-0142 becomes 5595550142).
- ZIP code: ALIS writes it as digits only (for example, 93730-0740 becomes 937300740).
Step 5: Complete the Resident's Profile
Complete these fields for each resident billed by claim.
Review Basic Information
- Go to a Resident Profile > expand Basic Information.
- Enter the resident's Sex at Birth and Birth Date.
- Enter the resident's Medical Record #. If left blank, it will not appear on the claim.
- Scroll down to the bottom of Basic Information, and click Update to save.
Update Medicaid Insurance
- On the Resident Profile, expand Insurance Information.
- Add or edit the resident’s Medicaid insurance record:
- To add, click + Add New Insurance.
- To edit, click Options > Edit on the existing record.
- Enter the Provider Name, Insurance Type, Account Number/Subscriber ID #, Group #, Effective Date(s), and Phone Number.
- Check Primary.
- Click Save.
Important: The insurance must be active and have a Subscriber ID # to be selected on a recurring charge.
Update the Physician Contact
If the physician is a Personal Contact:
- On the Resident Profile, expand Contacts.
- Click + Add Contact > Add New Personal Contact.
- Set Contact Type to Physician. When you do this:
- ALIS automatically checks Medical Contact under Additional Information.
- An NPI field appears under Personal Information. Enter the physician’s NPI. If left blank, the attending physician will not appear on the claim.
- Complete any other contact details as needed.
- Click Save & Go Back to return to the Resident Profile.
If the physician is a Community Contact:
- Go to the Community Contacts page, and open the physician’s contact.
- Update the physician’s NPI and any other contact details.
- Click Save.
- Under Associated Residents, confirm the resident billed by claim is listed.
- If the resident isn’t listed:
- Click + Associate Residents.
- In the Residents dropdown, select the resident’s name.
- Under Additional Information, confirm Medical Contact is checked.
- Click Associate Residents.
Important: Community Contacts are shared. Changes you save update this contact on every linked resident’s record, so verify your updates before saving.
Step 6: Add the Claims Recurring Charge
The recurring charge produces the service days that ALIS bills on claims.
- On the resident's profile, go to Recurring Charges.
- Add a recurring charge for the claims payer type.
- Select the billing item.
- Select the resident's Insurance.
- Enter the Service Start date, and a Service End date if the service ends.
- Enter the Unit Price and Quantity.
- Optional: Enter a Description to replace the billing item name on the claim.
- Optional: Select Hold from Billing only if waiver paperwork or an authorization is pending.
- Click Save.
The fields on the recurring charge depend on the billing item’s unit type in Billing Item Settings.
- Service Based items: Billed once per day. No Quantity is entered; enter the Price only.
- Time Based items: Enter the Quantity, the number of units per day. For example, 64 units of 15 minutes is 16 hours a day. The pane shows the hours per day and the daily total. Quantity can’t add up to more than 24 hours a day.
Tip: Held charges stay out of the Billing Queue until you clear the hold. See How to Hold and Release Medicaid Claims (Link Coming Soon).
What to Expect
Once setup is complete, ALIS adds the resident’s service days to the Billing Queue each night. To add the latest days right away, click Sync now on the Billing Queue.
Each claim bills one service line per day, with the quantity as the unit count and Price × Quantity as the line amount. The Recurring Charges grid shows the daily amount with a /day label.
Billing Center event rules and leaves of absence reduce billable days. The Billing Queue marks affected rows with a modified badge.
To export claims, see How to Generate Claims and Remove a Rejected Claim (Link Coming Soon).
Troubleshooting
Why a community can’t export claims
When you click Export Claims on the Medicaid Billing page, ALIS checks each community's setup first. A community that isn't ready appears under "This community is not set up for claims yet:" with a reason next to its name. No batch is created, so no claim numbers are used up.
"Does not have a phone number configured"
Add a Phone # under Billing Information (or Building Information) on the Community Details page. This message also appears if the number isn't a valid 10-digit number. See Step 4.
"Does not have a facility type / provider taxonomy code configured"
Add a Facility Type Code / Provider Taxonomy Code to the payer type's Billing Program. See Step 2.
I updated my settings, but an exported claim still shows the old values.
Changing these settings doesn't change files you've already exported. Redownloading an existing batch returns the original file. Claims you export after saving use the new values.
Why a resident doesn’t appear in the Billing Queue
No insurance on the charge
- Link the recurring charge to an active insurance record with a Subscriber #. See Steps 5 and 6.
Missing profile details
- Check the resident’s Date of Birth and Sex at Birth under Basic Information. See Step 5.
On hold
- Clear Hold from Billing on the recurring charge. See Step 6 and How to Hold and Release Medicaid Claims (Link Coming Soon).
On leave or charges ended
- Check the resident’s leaves of absence and Billing Center event rules for those days. Those days aren’t billable.
Not accrued yet
- Click Sync now on the Billing Queue to add the latest service days.
Already exported
- Check the Exported tab. The days are already on a batch.
Outside the date range
- Widen the Bill Through dates on the Billing Queue.