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This guide follows one visit from an attendant clocking in through to payment posted against the claim. This is the chain that determines whether your agency gets paid for care it has already delivered.

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The chain

Every arrow is a place the chain can break. Most unbilled revenue sits at the exception step.

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Step 1 — The authorization permits the visit

Before anything else, the member needs an active authorization with units remaining and a service code matching what you will deliver.
Once units are exhausted, delivered visits stop being payable. The care still happened; you cannot bill it. Watch Used against Units and request a new authorization before you reach the cap.
See Authorizations.

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Step 2 — The schedule generates a planned visit

Scheduling checks each visit against the authorization and flags conflicts — visits outside the date range, exceeding remaining units, or using an uncovered service code.
1

Review conflicts before the visit date

A flagged visit can still be delivered, but will not produce a payable claim.
2

Fix the authorization, not the flag

Extend the authorization or correct the service code.
See Scheduling.

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Step 3 — The attendant clocks in and out

The clock times determine actual units, which is what gets billed — not the planned times.

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Step 4 — Clear exceptions

This is the step that costs agencies the most money, because an unresolved exception is revenue that never bills.
1

Work the exception queue daily

Aggregator submission windows are time-bound.
2

Identify the actual cause

Failed geofence, missing clock-out, or units exceeding the schedule.
3

Apply the reason code that matches reality

It is submitted to the state aggregator.
4

Fix systematic causes

Repeated geofence failures for one member usually mean a wrong address, not attendant error.
Reason codes are a regulatory record. Applying a code that does not match what happened misrepresents visit data to the state. If you cannot determine what happened, escalate rather than guess.
See Time & Attendance.

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Step 5 — EVV matching produces a claim line

A bill code rule must exist for the payer, program, and service combination, and the service date must fall inside the rule’s effective window.
1

Confirm a bill code rule matches

No rule means no claim line. See EVV matching.
2

Check the match result

Result and Variance show what matching concluded.
3

Investigate any variance

A non-zero variance explains why billed units differ from visit units.
Denial Begin on a bill code rule is a temporal rule. Claims for service dates on or after that date are denied without a matching EVV transaction, even though earlier dates paid fine. A configuration that worked last year can start failing once this date passes.

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Step 6 — Claim lines become a claim

1

Review the claim before submitting

Check Units and Charge against the authorization.
2

Export the 837P

Submitted records the date.
Review before submitting, not after. A claim submitted with the wrong service code has to be corrected and resubmitted, which restarts the payment clock and risks the timely filing deadline.
See Billing.

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Step 7 — Post the remittance

1

Match the payment reference

Check/EFT against your bank deposit.
2

Post against the claims

Each claim’s Paid amount and status update.
3

Review adjustments by reason

Contractual reductions are expected. Authorization and EVV adjustments are not.
4

Work the denials

Correct and resubmit before the timely filing deadline.
See Remittances.

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Diagnosing a break in the chain

Work backwards from where the visit stopped:

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Recurring denial causes

Group your denials by reason. A reason that repeats is a process problem, not bad luck:
A valid authorization behind an expired payer contract still produces denials. When denials appear across many members at once, check the payer contract before investigating individual claims.

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Next

Month-end billing close

A repeatable monthly routine.

New member admission

Getting the authorization right from the start.