Resolve claim evidence gaps before release.

A held claim says why it is held.

Claims grouped by the rule that stopped them, with the dollars waiting under each. This is the product, on a fictional clinic.

• See it in the demo: the billing seat

Seven checks before a claim can leave.

Only a check marked as an error stops the claim. A claim that fails one is held for a person, with the evidence needed to fix it.

• 1. Authorization validity. The authorization is not RED, and the session's CPT codes are on it.
• 2. CPT whitelist. 97151 to 97158 and 99366.
• 3. Parent attendance. Compared with the payer's threshold. It is a warning, not a block.
• 4. Concurrent billing. No overlapping sessions for one client.
• 5. Supervision threshold. A non-blocking advisory on supervision.
• 6. Signed note. A valid signature, with hashes that match what was signed.
• 7. Payer rule pack. Daily caps, rate ceilings, modifiers and authorization-cycle windows from the payer's reviewed pack.

Blocked claims wait in a review queue with the specific evidence needed to resolve them. They are never sent on blindly.

The denials ABA clinics see most.

ABA clinics meet a recurring set of denials that general-practice billing software is not built to catch. CARC 197 (precertification, authorization or notification absent) is the costly one, and it is usually triggered when units run out before the reauth is submitted. CARC 16 (claim or service lacks information, or has a submission or billing error) sends you to check a missing NPI, date of birth or authorization number. CARC 96 (non-covered charge) sends you to the accompanying remark code and the plan's ABA exclusions.

When a remittance returns, ABACare classifies it by CARC and RARC code into its own buckets: authorization expired, authorization absent, missing documentation, code or modifier mismatch, medical necessity, duplicate claim, out of network, parent attendance, and baseline data missing. Anything the categorizer cannot place lands in other and waits for a biller. Remittance (835) files are uploaded and reconciled today.

Once a denial is categorized, ABACare drafts the next review step, such as an appeal letter, from the session, authorization and payer evidence. A biller approves, edits or rejects it before anything is released.

A worked example, one held claim to release.

An example with invented figures, to show how the chain works. It is not a customer result and not a prediction for your clinic.

1. Evidence

   A two-hour session for CPT 97153 on a Tuesday. The authorization is found and the session was captured, but the note is still a draft.

2. Rule

   Check 6, signed note, is an error. The claim is held and the reason is named: unsigned note.

3. Proposal

   ABACare lists what is missing, the BCBA's signature. It does not sign for anyone.

4. Approval

   The BCBA signs. The signature is tied to a hash of what was signed, and the claim is checked again.

5. Action

   Billing releases the claim. Today a biller submits the 837P through the payer's own portal and attests to it, and ABACare records in plain words that it did not transmit the claim.

6. Audit

   If a remittance later returns CARC 197, the denial is sorted into an authorization bucket and an appeal draft is proposed for a biller to approve, edit or reject.

What ABACare does today, and what it does not.

• Does: build and validate the 837P, run the seven checks, and hold a failing claim with the reason named.
• Does: keep each claim linked to its session, authorization, note and clinician review, so the evidence packet is already assembled.
• Does: sort remittance evidence into denial buckets and draft the next step for a biller.
• Does not: send claims to a payer by itself. Billing staff submit through the payer's own portal and attest to it. Live transmission through a clearinghouse is not switched on yet.
• Does not: promise recovered dollars, appeal win rates or payer recovery rates.

Questions about ABA claim denials.

What does CARC 197 mean on an ABA claim?

CARC 197 is precertification, authorization or notification absent. In ABA it usually means the units ran out or the authorization expired before the reauth was submitted. ABACare's authorization state and the pre-claim check are built to surface that before the claim goes out.

Does ABACare submit claims to payers?

Not yet. ABACare builds and validates the 837P. A biller submits it through the payer's own portal and records the confirmation, and the record says plainly that ABACare did not transmit it. Remittance files are uploaded and reconciled.

What happens to a claim that fails a check?

It is held in the review queue with the reason named and the evidence needed, such as an unsigned note or an authorization that is out of date. Once the gap is fixed the claim is checked again.

Can ABACare write the appeal?

It drafts one from the session, authorization and payer evidence. A biller approves, edits or rejects the draft. ABACare does not state a win rate for appeals.