Part II · Appendix 19.1

Billing and Claims Submission

End-to-end billing workflow from documentation to claim submission and reconciliation.

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Billing and Claims Submission Policy and Procedure

Applies To: Applied Behavior Analysis (ABA), Speech Therapy (ST), Occupational Therapy (OT), and Physical Therapy (PT) Services

Systems Used: Office Puzzle, ClinicSource, Claim.MD

Purpose

The purpose of this policy is to establish general procedures governing billing and claims submission for services rendered by the organization. These procedures are intended to promote consistency, support accurate claim submission, and maintain compliance with applicable payer requirements and regulatory standards.

The organization maintains internal billing processes supported by electronic practice management systems. These processes are designed to ensure that claims submitted reasonably correspond to services documented in the clinical record.

Healthcare billing regulations and payer requirements may change over time. The organization maintains procedures intended to reduce administrative errors; however, the organization recognizes that clerical or administrative discrepancies may occur and provides mechanisms to identify and correct such issues when identified.

Scope

This policy applies to all individuals involved in clinical documentation, service entry, billing preparation, and claims submission, including:

Board Certified Behavior Analysts (BCBA)
Board Certified Assistant Behavior Analysts (BCaBA)
Registered Behavior Technicians (RBT)
Licensed Speech, Occupational, and Physical Therapists
Administrative and billing personnel
Supervisory staff responsible for clinical oversight.

Billing Systems

The organization utilizes electronic systems for documentation, billing preparation, and claims submission.

ABA Services

Applied Behavior Analysis services are documented and managed using:

Office Puzzle Practice Management Software

This system is used for:

Clinical documentation
Scheduling
Service tracking
Authorization tracking
Billing preparation

Office Puzzle functions as the primary system used for ABA billing preparation.

Therapy Services (Speech, Occupational, Physical)

Speech Therapy, Occupational Therapy, and Physical Therapy services are documented using: ClinicSource Therapy Management Software. ClinicSource supports documentation, scheduling, and billing preparation for therapy services.

Claims originating from Office Puzzle and ClinicSource are transmitted electronically through the Claim.MD clearinghouse.

Internal Billing Operations

The organization performs billing activities internally. The organization does not utilize external third-party billing companies for claims preparation or submission. Billing tasks are performed by designated administrative personnel using the systems identified in this policy.

General Billing Standards

The organization follows these general billing standards:

Claims submitted should correspond to services documented in the clinical record.
Services billed should reflect services delivered by qualified providers.
Claims should be prepared using information recorded within the organization's documentation systems.
Services billed should be consistent with applicable payer requirements and authorizations when applicable.
Documentation supporting billed services must be maintained within the clinical record.
Billing staff rely on information recorded in the documentation systems when preparing claims.

Claim Preparation and Submission

Claims preparation generally follows the process outlined below.

Step 1 - Service Documentation

Providers complete clinical documentation within the applicable system following service delivery (48 hours).

Step 2 - Service Entry and Review

Services are entered into either Office Puzzle or ClinicSource data management systems by the provider. Administrative staff may review records for completeness prior to claim submission when feasible.

Step 3 - Claim Generation

Claims are generated through the applicable electronic system based on documented services.

Step 4 - Claim Submission

Claims are transmitted electronically using the following structure:

Service	Documentation System	Claim Submission Method
ABA Services	Office Puzzle	Electronic submission through Claim.MD clearinghouse. Florida Medicaid web portal for Medicaid recipients not enrolled in managed care (manual entries).
ST / OT / PT	Clinic Source	Electronic submission through Claim.MD clearinghouse

Step 5 - Remittance Processing

Remittance advice from payers is reviewed and payments are posted according to payer responses.

Identification and Correction of Administrative Errors

Healthcare billing processes involve multiple administrative and documentation steps. When potential discrepancies or administrative errors are identified, the organization may perform corrective actions, which may include:

Internal review of the relevant documentation
Correction of administrative or clerical entries
Claim adjustments or resubmissions when appropriate
Payment corrections when required by payer policies

Corrective actions are conducted in accordance with applicable payer requirements and regulatory guidance.

Record Maintenance

Clinical and billing records are maintained in secure electronic systems. Records are retained in accordance with applicable federal, state, and payer record retention requirements.

Records may be made available for review by authorized entities, including payers, auditors, or regulatory agencies, when required.