Electronic Billing Definitions
What Terms Should I Be Familiar With Before Submitting Records for Reimbursement from a Funding Source?
Administrators, Billing
SETWorks offers an electronic billing solution. Read the following article to learn about terms and definitions used when working with electronic billing.
Terms and Definitions - Industry
EDI - Electronic Data Interchange. You'll see the acronym EDI frequently. It simply describes the system that allows agencies to send data electronically.
837 File - An 837 File is the electronic file that contains claim information. This file is submitted by a provider to a funder instead of printing and mailing a paper claim. An 837 File is a bill.
835 File - An 835 File is the electronic file that contains information about the payment status. This file is sent from a funding source back to a provider. An 835 File is a receipt.
Terms and Definitions - SETWorks Specific
What is a Batch in SETWorks?
A batch is a set of billable records that are grouped together for billing purposes.
Configuration Buttons
Add to Batch: Locks the selected activity record(s) and adds those claims to a SET-Works batch. Locks the batch integrity tied to the remittance advice on the SET-Works site. Use prior to submitting batch for billing.
Review Tab Buttons
Remove from Batch: Unlocks the selected activity record(s) and removes those claims from a SET-Works batch, so that they can be associated with a new batch. This changes the batch integrity on the SET-Works site, and unlocks the associated activity record. NOTE: Avoid using this for a claim that has already been submitted, as it makes it difficult to reconcile the remittance advice. Use this feature to remove claims from the batch prior to submitting the batch with no repercussions to the remittance advice.
Resubmit Claim: Sends the claim off again, as if it were a new claim, if for some reason the claim did not go through. This is used to resubmit certain line items rather than the entire batch.
Replacement Claim: Updates a single aspect of a claim (i.e., to update the number of hours logged on it or the rate of the service), and maintains the date and consumer information. This feature only works after the remittance advice has been received and processed.
Void Claim: Voids a record that was billed for previously and was paid by the funder, but that now needs to be nullified. This feature only works after the remittance advice has been received and processed.
Submit Batch: Sends the selected batch of claims to the funder for payment processing.
Replace/Resubmit Partial/Unpaid: This button allows the replacement and re-submission of a claim that was partially or completely unpaid by the funder and only submitting the necessary claims.
Relevant Privileges and Settings
Settings > Provider Build > Maintain Privileges > Electronic Billing:
Allow modification of Activity Records that have been billed. Warning! This can affect billing & reporting integrity. Always remember to update your payer via replacement or claim re-submission to maintain accuracy.
EVV - Allows modification of user location records after being sent to EVV vendor.
EVV - Is able to resubmit/correct EVV claims.
EVV - Is able to submit batch to EVV Vendors.
EVV - Is able to void EVV claims.
Is able to add billing file folders
Is able to add billing files.
Is able to delete billing files
Is able to move billing files and folders
Is able to remove records from a billed batch
Is able to replace/resubmit partial/un-paid claims
Is able to resubmit batch for billing purposes
Is able to resubmit claims
Is able to submit batch for billing purposes
Is able to submit replacement claims
Is able to void claims
Limit the ability to download Billing Files based on approved IP Address
Lock Group activity record when added to batch
Show Medicaid Status on E-Billing Screen
Show Re-Authorization Button on Billing Screen (only applicable in certain states with CPS services)
Show re-authorize IFC button on billing Screen (only applicable in certain states)
Show Re-Authorize Res Hab Button on Billing Screen (only applicable in certain states)
Show the view report button within the invoices grid
View Funder/billing related files - Permission/Access must be established prior to enabling this privilege. Please contact your SETWorks administrator for any questions.
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