How to Submit Electronic Billing

All users

Electronic billing submission is how SETWorks turns completed, billable service documentation into claims that go out to a funder or payer for reimbursement. Because Medicaid waiver and other HCBS billing depends on accurate units, authorizations, and Individual data, SETWorks checks each claim for common issues before it goes out and gives you a single screen to filter, review, and send claims in bulk. Submitting correctly and promptly keeps your agency's billing cycle on track and reduces denials and rework caused by preventable data errors.

Note: Resolve any Pre-Submission Errors on a claim (for example, a missing Individual gender or a Service without a billing code) before you submit it whenever possible. SETWorks may still let you run Bulk Submit on a claim that has open errors, but the funder or clearinghouse receiving it can reject it, which means more resubmission work later.

ℹ️ Note: Terminology can be modified within SETWorks to better fit the needs of your organization. If the terminology in our articles is not the same on your site, talk to your local administrator to assist in translation.

• You need permission to access Billing > Submit.
• A claim must already exist to submit it. Claims are generated automatically from completed, billable Activity Records through the billing pipeline, or can be created directly using Manual Claim Entry.
• To avoid Pre-Submission Errors, confirm in advance that the Individual's required demographic fields (such as gender) and the Service's billing code are filled in.

1. Open the Submit Billing screen.
   a. From the left navigation, expand Billing and select Submit. The screen opens on the Submission tab, where generated claims are grouped by Funding Source Name while they wait to be sent electronically.
2. Set your search criteria.
   a. Enter a From: and To: date range (both required), and optionally narrow the results with Organization:, Department:, Individual:, Funding Source:, Service:, Claim Status:, Activity Status:, and Signed Status:. Click Search to load matching claims.
3. Review the claims returned for a funding source.
   a. Use the + / - toggle next to a Funding Source Name to expand or collapse its claims. Each claim row shows the Claim Identifier, Individual, Billing Code, Status (for example, Ready to Process), an Errors count, 999 | 835 indicators, and the Claim Total. Expand a claim's own + toggle to see its underlying Service, Date, Units, and Billable Amount.
4. Check for pre-submission errors.
   a. Click the red Errors count on a claim row to open the Pre-Submission Errors window, which lists each Category (such as Individual Gender or Service Billing Code) alongside its Error message.
5. Select the claim(s) to submit.
   a. Check the box on the claim's row, or check the box next to the Funding Source Name to select every claim in that group at once.
6. Submit the selected claim(s).
   a. Click Bulk Submit. SETWorks sends the selected claim(s) out electronically and removes them from the Submission tab list once they've gone out.
7. Confirm the claim was submitted.
   a. Open the Review tab and search the same date range. The batch now shows a Submission Status of Submitted, Sent to Payer marked True, and the claim's own Status updated to Sent to Payer.
   b. Open the Files tab for the same dates to see the submission file SETWorks generated for that batch (for example, a file named DSW_Claim_Submission_...txt).
8. (Optional) Track a claim's history after submission.
   a. From the Submission or Review tab, click Actions on a claim and choose Data to open the Claim Data window. Its History, Confirmation, Timeline, and Divergence tabs show what's happened to the claim, and Guided Action tells you whether to Resubmit, use Replacement, or Void it if the claim no longer matches its last submitted snapshot.

What does the Errors badge on a claim mean, and will it block submission?
The red Errors count flags issues SETWorks found while building the claim, such as an Individual missing required demographic data or a Service without a billing code. Click the badge to see the full Pre-Submission Errors list. These are warnings, not hard stops — SETWorks will still let you run Bulk Submit on a claim with open errors, so it's best to fix them first to avoid a rejection from the payer.

What's the difference between the Submission, Review, and Billed tabs?
Submission is where generated claims wait before you send them. Once submitted, a batch moves to Review, where it's tracked with a Submission Status (like Submitted) and a Sent to Payer flag, and can be Approved, Denied, or Commented on. Billed is where claims land once a funder has responded, showing Denial Reason, Amount Paid, and Paid Date.

What do the 999 and 835 indicators mean?
These generally correspond to the standard electronic files funders return for claims: a 999 acknowledgment confirming the file was received, and an 835 remittance advice showing how a claim was paid or denied. A red icon typically means SETWorks hasn't received that file back yet for the claim.

Can I undo a claim after I submit it?
You can't delete a submitted claim outright. Depending on its status, use the row's Actions menu (or the Bulk Replace / Bulk Void buttons) to correct or cancel it, or Resubmit it if it needs to go out again. The Guided Action tab in the Claim Data window tells you which of these options applies to a specific claim.

Why are Bulk Replace and Bulk Void grayed out?
These actions only become available for claims in an eligible status, such as ones already sent to a payer that need correcting or canceling. A claim that hasn't been submitted yet, like one still marked Ready to Process, won't have these options enabled.

What is Manual Claim Entry for?
Manual Claim Entry lets you build a claim directly from an Individual's existing authorization instead of waiting for the billing pipeline to generate one from completed Activity Records. Select the Individual, then choose from their available Service, Authorization Code, Start Date, End Date, and Contract combinations.