Revenue
Billing & Revenue Cycle
Coralia's Billing & Revenue Cycle module is the claims engine of its all-in-one practice management platform for applied behavior analysis (ABA) therapy agencies: it turns approved, fully signed sessions into 837P claims (the standard electronic professional claim format), submits them through the Claim.MD clearinghouse, auto-posts electronic remittance advice (ERA 835), classifies denials into actionable categories, and manages family balances on a separate patient ledger.
The problem in real agencies
An ABA claim only pays if everything was true on the date of service: the session note carries the clinician, supervising analyst, and caregiver signatures; the client's authorization still had units for that CPT (Current Procedural Terminology) code; the RBT's (Registered Behavior Technician) credential was active; the payer contract and the provider's enrollment were in force; and the claim goes out inside the payer's timely-filing window. In most agencies those facts live in separate spreadsheets, and a miss surfaces weeks later as a denial.
The back half of the cycle is harder. Remittances arrive as ERA 835 files dense with claim adjustment reason codes (CARC) that a biller decodes line by line. Appeal deadlines differ by payer. Take-backs carry a federal 60-day report-and-return obligation. And the costliest failures are invisible: sessions that never billed at all, skipped by some silent rule, with no queue that explains why.
Family money is its own machine. Patient responsibility flows out of the same 835 files, but it must not accrue until coordination of benefits is settled; statements need a signed financial-responsibility consent and exactly one guarantor; hardship arrangements need structure. Agencies that push family balances through the payer claim pipeline end up sending wrong statements to parents who are already under strain.
How it works in Coralia
- 1
Generate claims through hard gates
Billing is never automatic. An approved, signed session waits in the Unbilled queue until an administrator runs Generate Claims. Each session then passes roughly twenty hard gates: the clinician–supervising analyst–caregiver signature check, a fail-closed insurance coverage gate, a mandatory authorization link with remaining units, diagnosis codes present, a rendering provider with an NPI (National Provider Identifier) and a billable, unexpired credential on the date of service, payer contract and per-provider enrollment status, payer-specific unit rounding, a modifier-aware rate, and the timely-filing window. Every skipped session keeps a plain-language reason that persists on the queue.
- 2
Submit clean 837P claims to the clearinghouse
Drafts missing a required NPI or policyholder identity cannot be marked ready — the readiness check names the gap and points at the exact screen that fixes it. On submit, Coralia re-verifies the three-way match (authorization, session documentation, claim) on every line: CPT code, date of service inside the authorization window, authorization number agreement, place of service, and the electronic visit verification (EVV) leg for payers that mandate it. The claim then transmits to the Claim.MD clearinghouse as an 837P payload; if transmission fails, it stays in ready with no half-updated state.
- 3
Post payer responses and ERA 835 remittances
Coralia reads the Claim.MD response feed and transitions each claim without hand-keying: accepted claims advance, rejections route to correct-and-resubmit, and warnings are left for human review. Rejections stay distinct from denials — a rejection is a pre-adjudication edit failure with no appeal right. ERA auto-posting runs Monday through Friday at 8 AM Eastern: remits match to claims by the payer's claim number first, paid, allowed, and adjustment detail posts line by line, corrected remits re-state the claim, and overpayments are preserved as credit balances.
- 4
Work denials with a built-in taxonomy and deadline-gated appeals
Every denial auto-classifies from its CARC codes into one of 10 categories — eligibility, authorization, coding, medical necessity, timely filing, duplicate, coordination of benefits, patient responsibility, contractual, other — each carrying a suggested biller action and a plain-language guidance sentence. Appeals are first-class records: filing is blocked after the payer's appeal deadline, each appeal carries a level (reconsideration, peer-to-peer, external review), and every exit resolves with an outcome — a payment arriving on an appealed claim stamps it overturned or partial automatically.
- 5
Reconcile take-backs and watch revenue health
When a payer reverses a payment, ERA posting re-opens the claim and creates a recoupment record on the federal 60-day report-and-return clock; billers resolve each as refunded, offset, or resolved, and voiding a claim returns its sessions to the unbilled queue and restores consumed authorization units. The Revenue tab reports collection rate, net collection rate, first-pass rate computed from status history, denial mix by category, accounts receivable aging in four buckets (0–30, 31–60, 61–90, 90+ days), and open recoupments with the nearest due date.
- 6
Run family balances on a separate patient ledger
Patient responsibility from ERAs accrues to per-line balance records with 8 statuses. A coordination-of-benefits hold keeps balances at estimated — not yet owed — until a human attests that coordination of benefits is complete. Statements require a signed financial-responsibility consent, resolve exactly one guarantor, and compute an exact balance-forward identity over an append-only ledger journal. Staff record payments in 6 methods with oldest-first allocation, set up installment arrangements, apply hardship or small-balance adjustments, and follow 3 dunning levels derived from agency-configurable day thresholds.
The specifics
Claims move through a 12-state lifecycle with an explicit allowed-transition map; paid, void, and written-off are terminal states.
Every status change writes a history row with its provenance — manual, clearinghouse, or ERA — and manual payer-state overrides require a written reason.
Denials auto-classify from CARC codes into 10 categories, with 29 codes explicitly mapped and each category suggesting one of 6 biller actions.
Appeals carry 3 levels (reconsideration, peer-to-peer, external review) and resolve with 4 outcomes; filing is blocked past the payer's appeal deadline.
Write-offs require one of 3 loss classifications, and the user who created the claim cannot approve their own write-off.
A weekly Monday batch runs 270/271 electronic eligibility checks through Claim.MD for every active or in-assessment client whose payer opts into automated verification.
The Billing screen has 8 tabs — Claims, Unbilled, Pending Review, Payers, Revenue, Eligibility, ERA, and Patient Balances — the last separately permissioned.
Per-payer configuration covers 13+ billing behaviors: filing and appeal windows, unit-rounding rule, EVV mandate, referring-provider requirement, concurrent-billing permission, and a modifier-aware rate schedule.
One-click rate population loads the Florida Medicaid 2025 fee schedule, modifier variants included, into every active payer's rate schedule.
Manual payment posting reconciles line payments to the claim payment within one cent, blocks over-payment, and resolves paid versus partially paid automatically.
Integrations
Claim.MD clearinghouse — 837P claim upload, claim response feed, ERA 835 retrieval (detail, PDF, and raw file), and 270/271 eligibility checks · The Coralia Brain — the per-agency AI copilot carries 8 billing tools to list and inspect claims, run claim generation, transition status, and record payments · Electronic Visit Verification — for payers that mandate EVV, the three-way match requires the caregiver visit verification before a claim can bill · HIPAA audit log — every skip reason, claim generation, payment, write-off, recoupment resolution, and coordination-of-benefits attestation is recorded
Access control
Six billing permission codes separate viewing, claim creation, editing, approval, and patient-balance viewing and management — the Patient Balances tab stays hidden without its own permission, and deep links to hidden tabs fall back to a visible one. Segregation of duties goes beyond roles: the user who created a claim cannot approve their own write-off, and agencies can set a dollar threshold above which patient adjustments and refunds also require the approval permission.
Frequently asked questions
Does Coralia bill sessions automatically?
No. Billing is never automatic: an approved, fully signed session waits in the Unbilled queue until an administrator explicitly runs Generate Claims. Each session then passes roughly twenty validation gates before it can bill, and any session that fails is skipped with a plain-language reason that persists on the queue — so stranded revenue is visible instead of silent.
How does Coralia handle claim denials and rejections?
It keeps them distinct. A rejection is a pre-adjudication edit failure routed to correct-and-resubmit with no appeal right; a denial is an adjudicated decision. Denials auto-classify from claim adjustment reason codes (CARC) into 10 categories, each with a suggested action — correct and resubmit, appeal, write-off candidate, route to patient billing, bill secondary, or review — and appeals are deadline-gated records with levels and outcomes.
What happens when a payer takes money back?
An ERA reversal re-opens the claim and creates a recoupment record whose due date reflects the federal 60-day report-and-return window for overpayments. Open recoupments and credit balances appear on the Revenue dashboard with the nearest due date, and a biller resolves each as refunded, offset, or resolved — an atomic flip that prevents resolving the same recoupment twice.
How does Coralia manage what families owe?
On a separate patient ledger, not the payer claim machine. Patient-responsibility amounts from ERA 835 files accrue per line and are held as estimated until someone attests that coordination of benefits is complete. Statements require a signed financial-responsibility consent and one resolved guarantor; staff record payments in six methods, set installment arrangements, apply hardship or small-balance adjustments, and follow configurable dunning levels.
Can I see the billing module before signing up?
Yes. Coralia's live demo at coralia.app/demo is a full synthetic agency with no sign-up required. You can open the Billing screen's eight tabs, walk the unbilled queue with its per-session skip reasons, follow claims through the 12-state lifecycle, and review the Revenue dashboard — all on synthetic data, with no real client information anywhere.