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Service Claims

Enter Consumers in Billing System

Policy: 

These policies, procedures and internal controls depend on the F/EA's billing processes.

Submit Service Claims to <<MMIS, State, Other>>

Policy: 

On a weekly basis, <<Staff Title>> produces a claim file for all payrolls processed in the most recent payroll cycle and any claims that were put on hold from a previous payroll cycle. Claims are produced per the format for electronic submission as specified by State/MMIS Provider. 

Each claim is verified for accuracy, completeness and compliance with program rules and regulation prior to submission. Claim file submissions are recorded in a control sheet.
 
After submitting a claim, a journal entry template is created and a posting made to the General Ledger.
Procedure: 

Process will vary based on program rules and F/EA systems.

Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. System access is restricted to those staff who have direct responsibility for service claim production
  2. Before completing the current payroll cycle’s billing, values in the billing system are reviewed to ensure that the billing from the last cycle was completed
  3. Each daily bill file is reconciled to the daily payroll report
    • Discrepancies are researched and resolved prior to proceeding
  4. Adjustments are made using control documents provided by the Payroll Department
    • All adjustments are stored for reconciliation purposes
  5. <<Staff Title>> reconciles supporting documents to ensure billing is submitted appropriately and payments are applied to claims appropriately.
  6. <<Staff Title>> creates journal entry templates.
    • Each journal entry template is used as a control document.
    • Each reconciliation document is prenumbered
    • <<Staff Title>> signs and dates verifying accuracy
  7. F/EA Accountant reviews supporting documents and journal entry template for completeness and mathematical accuracy.
    • F/EA Accountant signs and dates journal entry template.
  8. <<Staff Title>> reviews supporting documents and journal entry template for completeness and mathematical accuracy.
    • <<Staff Title>> signs and dates journal entry template.
  9. F/EA Accountant posts journal entries.
  10. F/EA Accountant reconciles General Ledger to appropriate supporting documents at year-end.
  11. F/EA Accountant produces reconciliation documents, verifies, signs and dates.
  12. <<Staff Title>> reviews, verifies, signs and dates reconciliation documents

Process Service Claim Payments

Policy: 

Claims submitted to <<MMIS/State>> for payments made on behalf of consumers for tax purposes are referred to as service claims. 

On a weekly basis, or as payments for service claims are received by F/EA, <<Staff Title>> loads the electronic payment remittance file to Billing System. The payment is reconciled to open claims in Billing System. Any denied claims are noted, accounted for and researched.
 
Open claims in the ETS billing system are reconciled to the Accounts Receivable on the Wash Claim billing control sheet. After reconciling and resolving any discrepancies, <<Staff Title>> creates a journal entry template to post the service claim payments to the General Ledger.
 
After reviewing the journal entry template and supporting documents, the <<Staff Title>> and F/EA Accountant sign and date the journal entry template. The F/EA Accountant posts payments to the General Ledger (See Policy and Procedure 20.5).
 
After posting payments, a reconciliation of the General Ledger account to ETS Accounts Receivable is performed (See Policy and Procedure 2.15).
Procedure: 

Post Service Payment to Billing System

<<Process will vary depending on State payment process and F/EA billing system and processes>>

Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. <<Staff Title>> reconciles Cash Account Transactions-Batch Control report to Remittance Advice to the electronic payment file to ensure payment file has been received appropriately.
  2. <<Staff Title>> reconciles payment file that has been applied to open service claims to remittance advice to ensure payment claims were not misapplied to open claims.
  3. <<Staff Title>> enters all values in a billing control document.
  4. <<Staff Title>> reconciles the Accounts Receivable report to billing control document to ensure that all payments and denials have been correctly accounted for.
  5. Paper and electronic copies of all documents are maintained for a minimum of 7 years per File Retention Policy.

Process Denied Service Claims

Policy: 

Service Claim Denials are processed within 10 days of an Service Claim payment being posted. The <<Staff Title>> researches each denied claim. Where applicable, the <<Staff Title>> adjusts the claim and resubmits it. The Service Claim Accounts Receivable is updated per denials and resubmissions.

Procedure: 

 

  1. After a payment is posted for an service claim submission  <<Staff Title>> completes denial process within 10 days
  2. <<Staff Title>> goes to <<File Path>>
  3. <<Process will vary depending on state and F/EA procedures>>
Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. <<Staff Title>> researches each denial and corrects denials as appropriate.
  2. <<Staff Title>> reconciles denied and rebilled amounts from claim to billing system.
  3. A Billing Control sheet is completed showing denied and re-billed claims.
  4. The year-to-date accounts receivable balance for service claims in the billing system is reconciled to the Accounts Receivable balance in the F/EA Billing Control sheet.
  5. A Tracking Number confirmation receipt is printed after submitting rebilled denials to State submission website.
  6. F/EA Accountant posts journal entries.
  7. F/EA Accountant reconciles General Ledger to appropriate supporting documents at month end.
  8. F/EA Accountant produces reconciliation documents, verifies, signs and dates.
  9. <<Staff Title>> reviews, verifies, signs and dates reconciliation documents

Post Service Claims and Payments to General Ledger

Policy: 

After successfully submitting a valid service claim file, the <<Staff Title>> reconciles the recently submitted claim to the Accounts Receivable balance in the billing sub-system. The <<Staff Title>> updates the Billing Control form with the applicable Accounts Receivable values and creates a journal entry template. 

After reviewing the journal entry template and researching and resolving any discrepancies, the F/EA Accountant posts applicable entries to the General Ledger. A reconciliation process is performed monthly and is reviewed by the F/EA Accountant and <<Staff Title>> (See Policy and Procedure).
 
After receiving a payment for a previously submitted claim, <<Staff Title>> applies the payment to open claims in the Billing System and tracks denied claims. The <<Staff Title>> updates the Billing Control form and reconciles the payment to the Accounts Receivable balance in the billing system. The <<Staff Title>> creates a journal entry template.
 
After reviewing the journal entry template and researching and resolving any discrepancies, the F/EA Accountant posts applicable entries to the General Ledger. A reconciliation process is performed monthly and is reviewed by the F/EA Accountant and <<Staff Title>> (See Policy and Procedure 2.15).
Procedure: 

Post Service Billing to General Ledger

Performed Monthly
Account <<99999>>
  1. <<Insert Process>>

Post Accruals to General Ledger

Performed Monthly
Account <<99999>>
  1. An accrual is the amount that has been put on hold, meaning it has not yet been submitted as a claim to the Program, but must be counted in Accounts Receivable
  2. <<Insert Process>>
 
Post Payments to General Ledger
Performed Monthly
Account <<99999>>
 

<<Insert Process>>

Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. <<Staff Title>> reconciles supporting documents to ensure billing is submitted appropriately and payments are applied to claims appropriately.
  2. <<Staff Title>> creates journal entry templates.
    • Each journal entry template is used as a control document.
    • Each reconciliation document is prenumbered
    • <<Staff Title>> signs and dates verifying accuracy
  3. F/EA Accountant reviews supporting documents and journal entry template for completeness and mathematical accuracy.
    • F/EA Accountant signs and dates journal entry template.
  4. <<Staff Title>> reviews supporting documents and journal entry template for completeness and mathematical accuracy.
    • <<Staff Title>> signs and dates journal entry template.
  5. F/EA Accountant posts journal entries.
  6. F/EA Accountant reconciles General Ledger to appropriate supporting documents at year-end.
  7. F/EA Accountant produces reconciliation documents, verifies, signs and dates.
  8. <<Staff Title>> reviews, verifies, signs and dates reconciliation documents