Medicaid claims billing uses terms from electronic billing standards, your payer's requirements, and ALIS. This glossary explains what each term means, where the value comes from, and where you'll see it.
See How to Set Up Medicaid Claims Billing for Medicaid Billing setup steps.
Claim Files and Partners
These are the files and organizations involved in sending claims and receiving payment.
| Term | What it means | Where you'll see it |
|---|---|---|
| 837I | The standard electronic claim file for institutional providers. ALIS generates one 837I file for each claim batch you export. | Downloaded as a .txt file when you click Generate & Download on the Medicaid Billing page. |
|
835 (ERA, remittance) |
The payer's electronic payment file. It lists what the payer paid, adjusted, or denied for each claim. Also called an Electronic Remittance Advice (ERA). | Releasing soon. Uploaded to ALIS with Upload ERA on the Medicaid Billing page. |
| Clearinghouse | A company that checks your claim files for errors and routes them to the right payer. Some communities submit directly through the payer's portal instead. | Outside ALIS. You upload the 837I to your clearinghouse or payer portal. |
| Companion guide | A document your payer publishes that lists the exact values and formats it expects on claims. It's the source for most of the codes in this glossary. | Outside ALIS. Request it from your payer or clearinghouse. See example for California: Medi-Cal Companion Guide. |
Payer and Submitter Identifiers
These IDs tell the payer who is sending the claim and where it's going. Enter them in Claim Submission Details on the payer type's Billing Program.
| Term | What it means | Where you get it |
|---|---|---|
| Payer Name | The payer's name as it appears on the claim. | Payer companion guide |
| Payer ID (EDI) | The payer's electronic ID, used to route the claim to the right payer. | Payer companion guide or clearinghouse payer list |
| Receiver ID | The ID of the organization receiving the file, either the clearinghouse or the payer. | Clearinghouse or payer enrollment |
| Submitter ID | The ID the payer assigned to your community as the sender of claims. Each community has its own, even within one company. | Payer or clearinghouse enrollment |
Provider Identifiers
These identify your community as the billing provider.
| Term | What it means | Where you get it |
|---|---|---|
| Billing NPI | The community's 10-digit National Provider Identifier, the federal ID for health care providers. | Your community's NPI records. You can look it up in the NPPES NPI Registry. See NPPES NPI Registry. |
| Tax ID | The community's federal tax ID (EIN). | Your accounting or business office records |
| Provider Taxonomy Code | A 10-character code that identifies the provider's type and specialty. 310400000X identifies an assisted living facility. More specific codes exist, such as for memory care. | Payer companion guide or the NUCC taxonomy code set. See NUCC Health Care Provider Taxonomy. |
| Facility Type Code | A one- or two-character code that identifies the type of facility on the claim. Medi-Cal uses 33. | Payer companion guide |
Service Codes
These describe the service billed on each claim line. Enter them on the billing item.
| Term | What it means | Example |
|---|---|---|
| Procedure Code (HCPCS) | The standard code for the service being billed. | T2031 (Assisted Living Waiver) |
| Procedure Code Qualifier | Identifies which code set the procedure code comes from. | HC (HCPCS) |
| Claim Modifier | A two-character code that adds detail to the procedure code, such as the resident's care tier. ALIS supports U1 to U5 and writes up to four per service line. | U2 |
| Billing Unit Type | For Time-Based items, what one unit represents. | 15 Minute(s) |
File Control Numbers
Every claim file carries numbers the payer uses to tell files apart. The payer can reject a file that reuses a number it already received from your community.
| Term | What it means | Where you get it |
|---|---|---|
| Interchange Number | The control number on the outer envelope of each claim file. It increases with every file. | ALIS assigns it automatically. When switching systems, take it from the last file your old system submitted. |
| Batch Number | The number that identifies a group of claims within a file. In ALIS, it also appears in the claim file name. | ALIS assigns it automatically. When switching systems, take it from the last file your old system submitted. |
Tip: Only communities switching from another billing system need these. Enter them as Starting Interchange Number and Starting Batch Number on the Billing Program before the first export.
Resident Claim Details
These come from the resident's profile and appear on each claim.
| Term | What it means | Where it's entered in ALIS |
|---|---|---|
| Medical Record Number | The community's record number for the resident. Optional on the claim. | Resident Profile > Basic Information |
| Attending Physician NPI | The resident's physician's NPI. Optional on the claim. | Resident Profile > Contacts, or the Community Contacts page |
| Subscriber # | The resident's Medicaid ID number. A recurring charge can only be linked to insurance that has one. | Resident Profile > Insurance Information |
| Insurance Sequence | Whether the insurance is primary, secondary, and so on. Other coverage may need to be billed first. | Resident Profile > Insurance Information |
ALIS Claims Terms
These are terms you'll see on the Medicaid Billing page, the Bill Hold Report, and the Aging Report.
| Term | What it means |
|---|---|
| Billing Queue | Service days that have accrued but aren't on a claim yet. ALIS adds new days every night. |
| Batch | A group of claims exported together as one 837I file. |
| Modified badge | Marks a Billing Queue row with fewer billable days than the full period, usually because of a leave of absence or an ended charge. |
| Hold from Billing | A recurring charge setting that keeps service days out of the Billing Queue until you release it. |
| Unsubmitted | The Aging Report column for charges that posted to the general ledger but aren't on a claim yet. |
| RA Linked | Releasing soon. Shows the remittance (835) that paid a batch. |
| Trace number (TRN) | Releasing soon. The payment's EFT trace number from the 835. Use it to match a remittance to the payer's deposit. |
| Voided | Releasing soon. Marks Billing Queue days returned from a claim the payer denied in full. A void cannot be undone. |