Basic eBilling Workflow

Terminology can be modified within SETWorks to better fit the needs of your organization. If the terminology in our articles are not the same on your site, talk to your local administrator to assist in translation.

Configuring a Billing Batch

Global Action Menu > "Manage Batches & Select Billing" > "Configuration" tab (automatically selected on page load)

Scroll down to the Manage Batches section and click "add new batch."

Choose a name for your batch; we recommend naming it after the timespan of records you will include ("April 2025", "Medicaid 10/1 - 10/15", etc.). Click insert.

Now at the top of the configuration tab, adjust your date filters to cover the range of dates you want to bill, include any other filters you need, and then click "apply filters." Any funding sources that have records tied to them during that date range will show in the grid below:

Open the funding source line that you want to include in your batch (1), and then if you want to review the dates you are adding for each consumer/service, you can open those lines too (2). Check the boxes for all the records you want to include, and then scroll down to "Available Batches" and make sure the batch you just made is selected. Click "add to batch" (3):

Data Validation

At this stage, we recommend running a pre-billing report on the newly created batch. This QA step will help to prevent common data-related billing errors.

Most providers can use: Activity Record Billing Report Export with Subtotals and Exceptions

TCM providers can use: Activity Records TCM Billing Excel Report (page 2 of this report)

Adjust your date range to cover records in the batch you just created (1). This will adjust which batches are listed in the batch filter. Select the batch you just created (2). Click "generate report" (3):

Use this report to verify the data before the batch is submitted:

1. Data requirements vary by state and funder, but usually include consumer name, DOB, Medicaid ID, gender, diagnosis code, and billing code. Sometimes they also include service location code and authorization code.
   
2. Logistical data: Is the rate for each service accurate? Are you expecting a consumer to have one hour of service but the report shows 13 hours?
   
3. The "Status" column will show some common potential errors based on internal checks in the system.
   

Depending on your billing requirements and type of services, you may need additional pieces of data not included in these reports like referring/rendering/attending provider, or contract-specific NPI or taxonomy code. 

Submitting a Batch

Post-billing Reporting

1. Claim rejections:
   
1. Big Bird had a typo in his Auth Code, so all his claims were rejected for that service. The billing specialist would check boxes to select all the records under that service, and then click "resubmit claim."
   
2. A new funder started requiring authorization codes but the provider didn't know, so the entire batch of claims was rejected. The billing specialist can scroll to the bottom of the review tab and resubmit the batch as a whole.
2. Takebacks:
   
1. After these claims were paid by the funder, the billing specialist found out that staff falsified records for Big Bird on October 9th, and in fact did not provide services that day, which means they need to take back those two records. They will check boxes for all the records they want to keep (October 7th and 17th) and leave the records on the 9th unchecked, and then click "replacement claim."
   
2. After these claims were paid by the funder, the billing specialist realizes they accidentally kept billing for a consumer after the consumer left services, and they need to take back all records for that consumer in the batch. The billing specialist will select all the records for that consumer in the batch and then click "void claim."
3. Activity Record corrections:
   
1. After these claims were paid by the funder, the billing specialist realized that the staff chose the wrong authorization for Big Bird on some records, and all of the employment records should have been under Day Hab. The billing specialist will check the boxes for all of the dates under the employment service, and then click "void claim." They will then remove the records from the batch, correct the authorization, and submit them in a new batch.
   
2. After these claims were paid by the funder, staff alerts the billing specialist that they accidentally made their employment record for Big Bird on the 7th to be one hour instead of three hours. The billing specialist will remove the record from the batch, correct the time, add it back to the batch, and then select all Big Bird's employment records and click "replacement claim."
4. Service corrections:
   
1. After these claims were paid by the funder, the accounting specialist notices that the new rate increase was not put into SETWorks and these claims were submitted and paid at lower rates. The rates in the service utility can be updated, and then the billing specialist will check the boxes to select all the dates under that service, and then click "replacement claim."
   

If there is uncertainty about the correct order of operations for a billing correction, please reach out to ebilling@setworks.com for assistance.