Billing & RCM
Carelytic produces CMS-1500 (837P) and UB-04 (837I) from a single Claim model and submits through whichever clearinghouse your agency uses. Per-payer rate overrides and 4 unit rounding modes mean the same service bills correctly to Medicaid PCA, commercial, and private pay without code changes.
Clearinghouse pipeline
Carelytic submits 837P / 837I, parses 835 ERAs, runs 270/276 eligibility and claim-status checks, and tracks payer enrollment across the major US healthcare clearinghouses. Whichever one your agency runs today, we keep it. No "switch to ours or you can't bill" gating.
Pre-built integrations for the clearinghouses HHAs actually use:
Using one we don't list? Tell us during onboarding — adapter pattern means new integrations land without touching tenant data.
Carelytic produces 837P (CMS-1500), 837I (UB-04), reads 835 ERAs, runs 270/271 eligibility, 276/277 claim status, and 277CA acknowledgments. One Claim model, one credentials store, one enrollment dashboard — no matter which clearinghouse you run.
For payers that need exact X12 instead of the clearinghouse's normalized format, we ship raw 837 files. JSON / structured submission is the default; X12 is the escape hatch.
Submitted → accepted → rejected → paid status flows back from your clearinghouse without manual SFTP polling. Visible per-claim on the billing queue and rolled up in AR aging.
Submit enrollments per transaction type (837P, 837I, 835, 270, 276), poll status, surface rejected / in-progress / enrolled. One dashboard for every payer relationship in your book.
ERA files parse into batch postings with the CARC adjustment library, exception queue, and write-off workflow. CARC code library covers the full CMS reason set.
Real-time eligibility
Click "Verify eligibility" on the patient's Payer & Eligibility tab.
Carelytic builds the X12 270 from Client + Payer + Tenant data, sends it through your
clearinghouse, parses the 271 into status / coverage dates / copay / deductible /
out-of-pocket, and persists an EligibilityCheck row for the audit trail.
Self-healing claim pipeline
Webhook dropped during a deploy? Clearinghouse rejected an enrollment that already existed? A 277CA never came back? Carelytic's claim pipeline assumes all of these will happen and recovers automatically — no support ticket, no manual reconciliation spreadsheet.
"Provider already exists" / "enrollment already exists" responses from any clearinghouse are caught and treated as success — Carelytic fetches the existing record and continues. Submitting the same claim twice never creates a duplicate.
Every claim status is reconciled against your clearinghouse nightly — 277CA acknowledgments and 835 ERAs that didn't fire a webhook are picked up automatically. Claims never silently stuck.
NPI digit count, EIN format, phone shape, address completeness — checked before the 837 leaves Carelytic. Fail-fast at submission instead of getting an obscure rejection back from the clearinghouse six hours later.
Per-payer rate overrides
Medicaid PCA bills at one rate, the same HCPCS to a commercial payer bills at another, private
pay is a third. Carelytics handles this through ServiceHCPCSMapping — set the rate
per (service line × HCPCS × payer) tuple and the billing pipeline picks the right one.
Reconciliation
Inbound ERAs parse into batch postings. Each ERA line links back to the originating claim. Mismatches surface in the exception queue immediately.
Full CARC code library with reason categories. Adjustments routed by reason — denial vs underpayment vs contractual write-off.
Discrepancies route to a queue with an assignee, due date, and resolution path (rebill / appeal / write-off).
Two-person rule on write-offs above a tenant-configurable threshold. Reason category required. Audit-logged with full diff.
AR aging
0–30, 31–60, 61–90, 90+. Per payer. Per service line. Per branch. Click any bucket to see the underlying claims, sorted by amount. Click any claim to see the hold reason, the ERA history, the visit it came from, and the patient's authorization status.
