Claim
An electronic billing document submitted to a government or insurance payer requesting reimbursement for services rendered. Claims include authorization codes, service codes, units delivered, dates of service, and provider information.
Also known as: claim · insurance claim · payer claim · EDI claim · billing claim
A claim is the billing artifact submitted to Medicaid, VA, MCO, or insurance companies. It typically includes the client's member ID, authorization code, CPT or HCPCS billing codes, units of service, dates, and provider NPI.
Claims are submitted electronically through the payer's system or a billing clearinghouse. The payer adjudicates the claim (approves, partially pays, or denies) within their standard processing window.
Common denial reasons include authorization mismatches (billing beyond approved hours), EVV non-compliance, coding errors, and duplicate submissions. Denied claims require review and resubmission within the payer's appeal window.
In home care, this means…
Generated from completed, EVV-verified visits. Submitted on a regular billing cycle. Denial rate is a key billing performance metric.
Related terms
Invoice →
A billing document sent to a private-pay client or insurance payer itemizing services delivered, dates, hours, rate, and total amount due. For government payers, the equivalent document is a claim.
Authorization →
A payer-issued approval to deliver and bill for specific services within a defined period or unit limit. Authorizations must be in place before scheduling any Medicaid, VA, or insurance-funded services.
EVV (Electronic Visit Verification) →
A technology system that electronically verifies caregiver presence, time, and location at a client's home at the start and end of each visit. Federally mandated for Medicaid and VA home care services.
AR (Accounts Receivable) →
Money owed to the agency for services already delivered but not yet paid. AR aging (0-30, 30-60, 60-90, 90+ days outstanding) is the primary indicator of billing health and cash flow risk.
Medicaid Waiver →
A state-administered Medicaid program that covers home and community-based services (including personal care) as an alternative to nursing home placement. Eligibility requirements, covered services, and reimbursement rates vary significantly by state.