Enhancements to Scheduling, Payroll Screen, CMS-485 Form, Billing & EVV

Configurable Alert Routing by Coverage Hours

A new Notification Coverage Hours setting is now available under Office Settings → Notifications. Agencies can define their business hours by selecting:

• Active days (e.g., Monday–Friday)
• Start and end times (e.g., 8:00 AM – 5:00 PM)
  

Note: After-hours are automatically calculated as everything outside the defined business hours — no separate configuration is needed.

2. Coverage Window Assignment per User

Each agency user on the Notifications screen can now be assigned one of three coverage windows:

• Business Hours — Notifications are received only during defined business hours.
• After Hours — Notifications are received only outside business hours (evenings, weekends, and holidays).
• All Hours — Notifications are received 24/7, at all times.
  

3. Holiday-Aware Routing

Any holidays defined under Office Settings → Holidays are automatically treated as After Hours. After-hours staff will receive alerts during holidays without any additional setup.

4. Visual Grouping on the Notifications Screen

Users on the Notifications screen are now visually grouped by their assigned coverage window (Business Hours → After Hours → All Hours), making it easy to see at a glance who covers which window.

5. Per-User Active Days Customization

In addition to the office-level business hours, active days can also be customized at the individual user level. If a specific user’s working days differ from the office default — for example, a user who covers weekends — their active days can be overridden directly on the Notifications screen. This ensures each user only receives alerts on the days they are on duty, without affecting the office-wide settings.

Notifications Covered by Coverage Routing

The following Actionable notifications now follow coverage hour rules. All other Informational notification types continue to be sent to selected users regardless of the time of day.

Default Behavior

All existing users are automatically set to “All Hours” — current notification behavior remains completely unchanged until an admin explicitly assigns different coverage windows.

“Tasks Not Updated” Notification at Clock-Out

Overview

A new notification is added that notifies the agency’s staff whenever a caregiver clocks out of a shift without updating their assigned tasks. This helps you catch incomplete documentation immediately — no longer waiting to discover gaps during reviews.

How It Works

When a caregiver clocks out — whether via the mobile app, IVR, web portal, or offline sync — the system checks if any tasks were left un-updated. If so, your designated staff are notified right away via email and/or SMS.

Setting It Up

• Email alerts: Go to Office Settings → Notifications and enable “Tasks Not Updated at Clock-Out”. Choose which team members should receive the alert.
• SMS alerts: Go to Admin Settings → Configuration → Configure SMS Services and enable the matching SMS option.

Both are off by default — simply toggle them on when you’re ready.

Enhancement to Increase Size of Visible Training Window (New UI)

We have enhanced the Training section on the Caregiver and Office Staff profiles in the Agency Portal (New UI) to display more records at a glance, improving usability and reducing excessive scrolling.

What’s New – Expanded Visible Rows:

The Training and Training Reports tabs have been updated to improve data viewing and navigation:

• Up to 10 rows are now displayed by default.
• A scroll bar is available to easily navigate through additional records.
• The user can customize how many rows you see using the “Show Rows” option along with Pagination.
• § Users can choose from 10, 20, 30, 40, 50, 100, or 200 rows per page, consistent with other forms and views.

• This enhancement gives you greater flexibility and a smoother experience when reviewing training/training report data.

UI Enhancement: Tab-Based Layout

• The interface has been upgraded with a tab-based layout for better usability and organization.
• Previously, both Training and Training Reports (from LMS) were displayed within a single window.
• Now, each section has been given a dedicated tab and separate view, making it easier to navigate and focus on specific information.
• This improvement enhances the overall layout, clarity, and user experience.

Default Sorting: Records are now sorted by Completion Date (Descending) by default, so the most recently completed trainings appear first.

Applicable Areas:

• Caregiver Profile → HR & Rates → Training Section (New UI)
• Office Staff Profile → HR & Rates → Training Section (New UI)

Impact: Eliminates the need for excessive pagination or clicking to view recent training records, giving agencies an immediate, comprehensive view of training status at a glance.

Consistency: All other Training section functionalities (adding trainings, editing, filtering, and reporting behavior) remain unchanged.

This update enhances training data visibility, highlights recent completions with default sorting, and provides a more efficient, streamlined view without changing existing workflows.

Multi- Select Coordinator and Supervisor Drop-Downs

CareSmartz360 now supports associating multiple Care Coordinators with a client and multiple Supervisors with a caregiver, enabling flexible oversight across locations. Users can multi-select Care Coordinators in the Client profile and Supervisors/Managers in the Caregiver profile, with no change to existing workflows.

Notifications that were sent to only 1 Care-Coordinator/Supervisor will now be sent to every selected Care Coordinator/Supervisor. Reports that include Care Coordinator or Supervisor fields will display all associated users as comma-separated values.

Blended Overtime Calculation Method

CareSmartz360 now supports Blended Overtime calculation, providing agencies with an additional method to calculate overtime for caregivers who work multiple shifts at different pay rates within the same payroll workweek.

What’s New – Overtime Calculation Method

A new setting has been introduced under Office Settings → Payroll → Overtime, allowing agencies to choose how overtime is calculated.

The following options are available:

• Straight Time (Default): Overtime is calculated using the base rate of the shift where overtime is incurred.
• Blended Average: Overtime is calculated using a weighted average (blended) regular rate based on all eligible earnings and hours worked during the payroll workweek.

When Blended Average is Selected

When the Blended Average calculation method is selected, the system first determines a Blended Regular Rate (RR) by considering the caregiver’s total straight-time earnings and total hours worked within the payroll workweek. The calculated blended rate is then used to determine the overtime premium for all applicable overtime and double overtime hours.

The calculation follows the formulas below:

Blended Regular Rate (RR)

RR = Total Straight-Time Earnings ÷ Total Hours Worked

Overtime (OT) Amount

OT Amount = (OT Units × Base Rate) + ((OT Multiplier − 1) × RR × OT Hours)

Double Overtime (DOT) Amount

DOT Amount = (DOT Units × Base Rate) + ((DOT Multiplier − 1) × RR × DOT Hours)

OT Rate (Displayed on Payroll Screen)

OT Rate = OT Amount ÷ OT Units

DOT Rate (Displayed on Payroll Screen)

DOT Rate = DOT Amount ÷ DOT Units

Calculation Behavior
When Blended Average is enabled:

• The blended regular rate is calculated using all eligible earnings and worked hours within the caregiver’s payroll workweek.
• Straight-time earnings from hourly, unit-based, visit, payable meeting, and compensable travel time are included in the blended rate calculation.
• Existing overtime and double overtime hour classification rules remain unchanged. Only the overtime calculation methodology is updated.
• Breaks continue to follow the agency’s existing paid or unpaid break configuration without any change in behavior.
• Holiday overtime continues to follow the existing calculation rules and is not impacted by the blended overtime methodology.
• Visit earnings and visit duration are included while calculating the blended regular rate; however, visit shifts continue to follow their existing payout logic and do not receive a blended overtime premium.
• Blended Overtime applies only to caregiver payroll calculations and does not impact invoice generation or client billing. Invoice amounts and billing calculations continue to follow the existing billing rules without any changes.

Payroll Screen Enhancements

The payroll screens have been updated to clearly identify blended overtime calculations while maintaining the existing payroll workflow.

When Blended Average is selected:

• The existing Regular, OT, and DOT sections remain unchanged.
• Overtime rows display “Overtime Amount (Blended)” for applicable OT and DOT calculations.
• OT and DOT rates displayed on the payroll screen are automatically derived using the blended overtime calculation methodology.
• Informational tooltips are available to explain how blended overtime is calculated.
• Existing payroll layouts and user workflows remain unchanged.

Payroll Finalization

Blended overtime calculations remain dynamic until payroll is finalized.

• Before payroll finalization, if additional shifts are added or modified within the same payroll workweek, the blended regular rate and overtime premium are automatically recalculated.
• Once payroll is finalized, the blended regular rate, overtime rates, and overtime premium amounts are locked and will not be recalculated, even if shifts, pay rates, or overtime settings are changed later.

Reports and Exports

All existing payroll reports and export formats retain their current structure and layout.

When Blended Average is enabled:

• Payroll reports automatically reflect blended overtime calculations.
• Payroll exports generate updated overtime rate and amount values based on the blended overtime methodology while preserving the existing file structure and integration format.
• No additional columns or changes to export layouts are introduced.

Impact

This enhancement provides agencies with a flexible and compliant overtime calculation method for caregivers working across multiple pay rates while preserving existing payroll workflows, reporting, exports, and billing processes. Agencies can adopt blended overtime calculations without impacting invoice generation or existing operational processes.

CMS-485 Form Data Capture & Generation

We have introduced a new feature to make it easier to capture all the information needed for the CMS-485 (Home Health Certification and Plan of Care) form. As part of this, a new assessment type called the CMS-485 Assessment is now available when you create a new assessment for a client. This assessment includes all the standard tabs you already use today, General Information, Medication, Additional Consideration, Goals, DME and Supplies, and Fall/Mobility & Transfer Ability, along with a brand-new tab called CMS-485 that has fields built specifically for this form.

You are not required to use this new assessment type to get a CMS-485 form. As soon as any assessment is completed for a client, whether it is this new CMS-485 Assessment or any other existing assessment type, a CMS-485 form is automatically generated for that client using whatever relevant information is available at that time.

If you use the CMS-485 Assessment, the form will be much more complete because this assessment is designed to capture every field the form needs. If you use a different assessment type, the form will still be created, but some fields may be left blank since that data was not captured.

Below is a detailed walkthrough of every field on the CMS-485 form, where the information comes from, and how it behaves.

Patient HI Claim Number is not a new field you need to fill in. It is automatically filled using the Medicaid Number already saved in the client’s profile, so there is nothing extra to enter here.

Medical Record Number is a brand-new text field that has been added to the General Information section of the client profile. Whatever you type into this field in the client profile will automatically show up on the CMS-485 form under this same label.

Patient Name and Address are pulled directly from the client’s profile as they appear there today. There is no change to how these are entered; they simply flow through to the form automatically.

Date of Birth works the same way. It is pulled from the date of birth already saved on the client’s profile and requires no separate entry.

Sex on the form is filled in using the Gender field from the client profile. Only Male or Female will be used to populate this field. If the Gender field in the profile is empty, missing, or set to something other than Male or Female, this field will simply be left blank on the form, and you will be able to type it in manually directly on the form itself.

Principal Diagnosis is filled in using the Primary Diagnosis code already set in the client profile. If you change this diagnosis code directly on the CMS-485 form itself, the system will show you a pop-up asking you to confirm the change, since updating it here will also update and overwrite the Primary Diagnosis code stored in the client profile. You will also see diagnosis code suggestions based on ICD-10 lookup to help you find the right code while typing.

Surgical Diagnosis is a new checkbox that now appears next to each ICD-10 diagnosis code entry in the client profile, except next to the Primary Diagnosis, since a diagnosis cannot be both primary and surgical. Ticking this checkbox marks that particular diagnosis as surgical, and it will then appear under the Surgical Diagnosis section on the CMS-485 form instead of the general diagnosis list. If you add or change a surgical diagnosis directly on the form, you will again be asked to confirm before this change is saved back to the client profile.

Other Pertinent Diagnoses is not something you need to fill in by hand. Any diagnosis codes in the client profile that are not marked as either Primary or Surgical will automatically be listed here on the form.

Physician’s Name and Address are populated using a new contact type called Family Physician that you can now select when adding a contact to a client’s profile under the Relation with Client field. Once you add a contact with this relation, their name and address will automatically appear in this section of the CMS-485 form. This information remains editable directly on the form if you need to update it later.

Start of Care is a new date picker field that has been added to the General Information tab of the CMS-485 Assessment. You simply select the relevant date, and it will appear on the form under this label.

Certification Period is also a new addition to the assessment, with two date fields, a From date and a To date, that together define the certification period shown on the form.

Medication details, specifically the medicine name, dosage, and frequency, are pulled from the Medication tab of the CMS-485 Assessment. This connection works both ways: if you add a new medication or change an existing one directly on the CMS-485 form, the system will ask you to confirm before the change is saved back into the Medication tab of the assessment, so your records stay in sync in both places.

DME and Supplies is the new name for what used to be called just DME in the assessment. Whatever items you select in this section of the assessment will appear on the CMS-485 form as a single comma-separated list.

Safety Measures are pulled from the Fall, Mobility & Transfer Ability section of the assessment, and like DME and Supplies, the selected options will be displayed as a comma-separated list on the form. A new free-text notes box has also been added in this section of the assessment so you can write in any safety measure that is not already covered by the standard checkbox options.

Nutritional Requirements on the form come from the Diet Type field, found under Dietary Restrictions on the Additional Consideration tab of the assessment. Whatever you select will be reflected on the form.

Allergies on the form are pulled from the Allergies section, also on the Additional Consideration tab of the assessment, so anything recorded there will automatically show up on the form.

Goals, Rehabilitation Potential, and Discharge Plans are pulled from the Goals tab of the assessment. If a new goal is added directly on the CMS-485 form, you will be asked to confirm before it is saved back to the Goals tab of the assessment.

The new CMS-485 tab in the assessment contains several sections created specifically to support this form. Functional Limitations is a checklist where you can select one or more of the following fixed options: Amputation, Bowel/Bladder (Incontinence), Contracture, Hearing, Paralysis, Endurance, Ambulation, Speech, Legally Blind, and Dyspnea with Minimal Exertion. You can select as many as apply to the client.

Activities Permitted is another checklist with the fixed options: Complete Bedrest, Bedrest BRP, Up as Tolerated, Transfer Bed/Chair, Exercises Prescribed, Partial Weight Bearing, Independent at Home, Crutches, Cane, Wheelchair, Walker, and No Restriction. This section has a special behavior: if you select No Restriction, any other options you had previously selected will be automatically cleared, and you will not be able to select anything else while No Restriction remains chosen. If you then select any other option, No Restriction will be automatically unchecked, and all other options will become selectable again.

Mental Status is its own section with the fixed checkbox options Oriented, Comatose, Forgetful, Depressed, Disoriented, Lethargic, Agitated, and Other. If you select Other, a text box will appear so you can describe the specific mental status that is not covered by the listed options.

Prognosis is a dropdown field where you can choose only one of the following options at a time: Poor, Guarded, Fair, Good, or Excellent.

Orders for Discipline and Treatments is a free-text box where you can type out the specific amount, frequency, and duration of treatment ordered, with room for up to 1,000 characters. Whatever you type here will appear exactly as written on the CMS-485 form.

Nurse’s Signature and Date of Verbal SOC, where applicable, is a section where you can capture a digital signature from the nurse, with a date picker just below it to record the date of the verbal start of care, if applicable to this client.

The provider number on the form does not need to be entered manually. It is automatically filled in using the Provider ID set up under the Billing tab in Office Settings. If your agency has more than one office, the system will use the Provider ID belonging to the specific office that the client is assigned to.

For now, the physician signature is handled outside the system rather than through an online signing process. Once the form is filled out, you can download it as needed. You also have the option to email it directly to the client’s physician by selecting the Family Physician from the client’s saved contacts; doing so will send the completed CMS-485 form as an email attachment to that physician for their review and signature. Once you receive the form back from the physician with their signature, you will be able to upload the signed copy into the system so it is saved and stays attached to the client’s record for future reference.

This update is designed to reduce manual data entry, make sure information stays consistent across the client profile, assessments, and the CMS-485 form, and help you put together a complete and accurate plan of care more quickly.

Date Range Extension on the Agency Portal New UI for the Profile Areas

We have increased the maximum date range you can search across various sections of client and staff profiles. Previously, the date range available for filtering records in these areas was limited to a shorter window. With this update, you can now search and filter records using a date range of up to one year at a time, making it much easier to look back at older activity without having to search in smaller chunks.

This expanded date range is now available across the following profile types, wherever these sections exist: Client, Caregiver, Office Staff, Prospective Client, Caregiver Applicant, and Payer.

The following areas within these profiles now support the expanded one-year date range search: Notes, Tasks, Prospective Client Listing, Email Logs, SMS Logs, and Voice Mail Logs.

This update is designed to give you more flexibility when researching past activity, reduce the need to repeat searches in smaller date windows, and make it easier to find historical information across notes, tasks, and communication logs.

Assign a Caregiver to multiple Open Shifts on the Global Schedule Calendar

We have added a new capability to the Global Schedule Calendar that allows you to select multiple open shifts at once and assign them to a single caregiver in one go. This is available to Office Staff and Admin users who have write access to the Global Schedule Calendar and is designed to make it much faster to manage and fill open shifts instead of assigning them one at a time.

This functionality is available when the calendar is grouped by client. When you select one or more open shifts on the calendar, an option to assign a caregiver will now appear, allowing you to assign the selected shifts together rather than going into each shift individually. If you select any other type of shift then open-shift, this option will be greyed out as the caregiver assignment is provided under this feature for the open-shift(s) only.

When you open the caregiver dropdown to make this assignment, the list of caregivers shown will be based on matching criteria, specifically the office and territory of the caregiver as compared to the client. This works the same way it does today when assigning a caregiver to a single client’s schedule. If a caregiver does not match on these criteria, that is, if their office or territory does not align with the client’s office or territory, they will simply not appear in the dropdown list at all.

Once you select a caregiver from the dropdown and proceed with the assignment, the system will check for all the conflicts or alerts related to the selected shifts and display them to you, just as it does today. These conflicts and alerts will appear in the same way they currently do when assigning a caregiver through the bulk edit option for visits, so the experience will feel familiar and consistent with what you already use.

Please note that only one caregiver can be assigned at a time when using this multi-shift selection. You will not be able to assign different caregivers to different shifts within the same selection; the caregiver you choose will be applied to all the open shifts you have selected.

To help guide you while using this feature, a help text has been added next to the Assign Caregiver button. It reads: “Availability of the caregiver in the dropdown is based on the Office, Territory of the caregiver, and client. Please ensure that if you are selecting open-shift(s) for multiple clients, they should be of the same office and territory.” This is especially important to keep in mind if you are selecting open shifts that belong to more than one client, since the caregiver list shown will only reflect matches that work across all the selected clients’ offices and territories.

Export Selected or All Columns in Time Tracking

When exporting visit records from the time tracking views, you now have more control over which columns are included in your downloaded file.

When you hover over the download icon, you will see two options: Download Selected Columns and Download All Columns. Choosing Download Selected Columns will export only the columns you currently have selected in the grid, with no other columns included. Choosing Download All Columns will export every available column, with any duplicate columns appearing only once in the file.

These two download options are available across all time tracking views where the grid column selection feature is available.

This update gives you more flexibility to export exactly the data you need, whether it’s a focused view with just your selected columns or the complete dataset with all columns included.

Note: This Functionality is only available for the time tracking views where we have the select grid columns option available.

Selective Client/Caregiver Records Download on Global Schedule Calendar

You can now choose to download only specific records from the Global Schedule Calendar instead of always exporting the full list.

By default, clicking the download icon will continue to download all records, as it does today. However, if you select one or more rows before downloading, two options will now appear: Download All and Download Selected.

In the “Group by Client” view, if you select one or more clients on the calendar and click the download icon, you will see the Download All and Download Selected options. Choosing Download Selected will export records only for the client(s) you have selected.

Similarly, in the “Group by Caregiver” view, if you select one or more caregivers on the calendar and click the download icon, you will see the same two options.

Choosing Download Selected will export records only for the caregiver(s) you have selected.

This update makes it easier to pull focused exports for specific clients or caregivers, without having to download the full calendar and filter it afterward.

EVV/EDI updates

Massachusetts EOHHS EVV Specification V1.9.1 Updates

This release incorporates updates from the Massachusetts EOHHS Alternate EVV Technical Specification V1.9.1 to ensure CareSmartz360’s EVV submissions remain compliant with the latest state requirements.

What’s Changed

New Service Codes

• Added Value-Based Payment Service Codes for the Home Health Program and MAHEA Payer.

Payer, Program & Service Corrections (MASTF)

• Corrected Payer, Program, and Service Combinations for MASTF to align with the updated specification document.

Removed Incorrect Codes

• Removed incorrect Payer, Program, and Service Codes for the OneCares and SDABI/SDMFP programs that were previously included in error.

Reference Document

• MA EVV Vendor Specification V1.9.1 (PDF)

HHAeXchange: New Flat File Validation for Service Location Fields

What changed:
A new prebilling validation has been added to the HHAeXchange Billed Visit Import Report CSV export. The system now checks the Clock In/Out Service Location 1 and 2 fields for special or non-English characters and rejects files that contain them.

Why:
Special characters — such as accents, non-English letters, or uncommon symbols — in service location fields can cause claim export failures. This validation ensures cleaner data and smoother claim submissions.

Allowed characters:

• English letters: A–Z, a–z
• Numbers: 0–9
• Space, Hyphen (-), Apostrophe (‘), Period (.), Comma (,)

Error message displayed when validation fails:

“The Clock In/Out Service Location 1 or 2 fields contain unusual characters. Please use only standard English letters (A–Z, a–z) and common symbols.”

HHAeXchange Data Post Report: New “Auth Type” Filter for Payer-Specific Schedule Filtering

What changed:
A new “Auth Type” filter has been added to the HHAeXchange Data Post Report, placed before the existing Payer filter. This filter allows agencies to narrow down schedules by payer authorization type, eliminating the issue of duplicate schedule entries appearing across all payers on a client profile.

Why:
Previously, schedules on the HHAeXchange Data Post Report were duplicated across every payer associated with a client profile. For agencies handling high volumes of daily visit postings, this made it difficult to identify the correct payer and post the appropriate shift. The new filter ensures only shifts linked to the relevant authorization and specific payer are displayed.

Filter options:

• All (default) — Displays all HHAeXchange-configured payers in the Payer dropdown.
• Authorization — Shows only authorization-linked payers.
• Without Authorization — Shows only payers not linked to any authorization.

Key behaviors:

• The Payer dropdown dynamically updates based on the selected Auth Type value.
• The report grid reflects data corresponding only to the selected payer(s).
• The same filtering logic is applied to the posted JSON request payload for consistency.

CareBridge Manual Data Post: Bulk Update option

What changed:

A new Bulk Update function has been added to the CareBridge Manual Data Post view, allowing users to select multiple visits and apply reason codes in a single action — replacing the previous one-by-one workflow.

Key capabilities:

1. Bulk Selection — Users can select multiple visits simultaneously via checkboxes in the Manual Data Post view.

2. Bulk Reason Code Assignment — A bulk action option applies a reason code to all selected visits at once. The following reason code types are available:

• Manual Edit / Late & Missed Visit Reason Codes — available on the CareBridge Data Post Report.
• Location Reason Codes — available for states that support this feature (e.g., Tennessee), shown on the Location View tab.

3. Exception Visibility — Exception details (errors/reasons) are now visible directly in the list view without opening each individual record.

4. Late/Missed Visits Integration — Late and missed visits are surfaced in the same view, so users can manage them alongside other exceptions.

5. Confirmation & Feedback — A confirmation prompt appears before applying bulk updates, followed by a success/failure summary indicating how many records were updated.

Automated Fetching of 835 Remittance Files via SFTP or API

CareSmartz360 now supports automatic fetching of 835 Electronic Remittance Advice (ERA) files from clearinghouses via SFTP or API — eliminating the need for agencies to manually download and upload remittance files.

Key capabilities:

1. SFTP Connection Configuration — Administrators can configure SFTP connection details (host, port, username, credentials, remote directory path) per clearinghouse. All credentials are stored encrypted at rest.

2. API Integration Support — As an alternative to SFTP, the system supports fetching 835 files via clearinghouse-provided APIs with configurable authentication (OAuth, API key) per clearinghouse.

3. Automated Scheduled Fetching — The system automatically polls the configured SFTP server or API at a configurable interval (e.g., every 1, 6, 12, or 24 hours). Only new/unprocessed files are fetched to avoid duplicates.

4. Manual On-Demand Fetch — In addition to scheduled polling, administrators can trigger a fetch manually at any time.

5. File Parsing & Validation — Fetched 835 ERA files are validated against the ANSI X12 835 format, parsed, and linked to corresponding claims/invoices. Malformed files are flagged automatically.

6. Auto-Reconciliation — Parsed remittance data (payment amounts, adjustments, denial codes) are automatically mapped to existing claims. Unmatched remittances are flagged for manual review.

7. Logging & Notifications — Every fetch attempt is logged with status (success/failure), timestamp, file count, and errors. Administrators receive notifications on fetch failures or parsing errors.

New Feature: View Claim Status

Billing and accounting users can now fetch and view real-time claim statuses for posted (invoiced) records directly — without leaving CareSmartz360.

What’s New:

• New “View Claim Status” screen added under the Accounting tab, providing a centralized view of claim outcomes for all invoiced schedules.
• On-demand claim status fetch — click the Claim Status icon on any record to instantly see the payer’s response (accepted, rejected, pending, etc.).
• Filtering capabilities — filter records by Office (multi-select), Service Date Range, Clients, and Payers to quickly locate specific claims.
• Per-schedule visibility — claim status is displayed against each individual invoiced schedule, giving billing teams granular tracking.

Louisiana Medicaid EDI Integration (837P & 837I)

Summary

CareSmartz360 now supports EDI billing file generation (837 Professional and 837 Institutional) for Louisiana Medicaid, following the state’s companion guide specifications. This enables agencies serving Louisiana Medicaid beneficiaries to generate and submit claims directly through the platform.

What’s New

Louisiana Medicaid Clearing House Profile

• A new clearing house profile named Louisiana Medicaid has been added under the Billing Information screen.
• The profile fields and setup process remain consistent with existing clearing house profiles — no new workflow to learn.
• 837P (Professional) File Generation

– Users can now generate 837 Professional claim files compliant with the Louisiana Medicaid companion guide.

• 837I (Institutional) File Generation

-Users can now generate 837 Institutional claim files compliant with the Louisiana Medicaid companion guide.

Setup

1. Navigate to Billing Information screen.

2. Select the new Louisiana Medicaid clearinghouse profile.

3. Configure the profile using your Gainwell-assigned 7-digit Submitter Number.

4. Generate 837P or 837I files as per your standard EDI workflow — no changes to the existing process.

Texas Medicaid TMHP EDI Integration (837P & 837I)

CareSmartz360 now supports EDI claims submission for Texas Medicaid through the Texas Medicaid & Healthcare Partnership (TMHP) — the state-designated EDI gateway. Agencies can generate ANSI X12 5010-compliant 837 Professional (837P) and 837 Institutional (837I) claim files directly from the platform.

What’s New

Texas Medicaid (TMHP) Clearing House Profile

• A new clearinghouse profile for Texas Medicaid has been added under the Billing Information screen.
• Supports both direct EDI submission to TMHP (via SFTP or portal) and optional clearinghouse routing.

837P – Professional Claims

• Full 837P file generation compliant with the TMHP Professional Claims Companion Guide.
• Includes Texas Medicaid-specific edits, required loops, segments, and billing rules.

837I – Institutional Claims

• Full 837I file generation compliant with the TMHP Institutional Claims Companion Guide.
• Covers revenue codes, bill types, and frequency rules per the X12 5010 TR3 standard.
• Payer-specific segment binding for Texas Children’s Health Plan:

– Payer ID 76048 → “Texas Children’s Health Plan – CHIP”

– Payer ID 75228 → “Texas Children’s Health Plan – STAR/STARKIDS”

– Routed via Change Healthcare or Availity clearinghouse.

• Code-based checks ensure required segments (Loop 2010AB – Pay to Address Name; Loop 2300 – PWK) are generated only for applicable payer/clearinghouse combinations.

Setup

1. Navigate to the Billing Information screen.

2. Select the new Texas Medicaid clearing house profile.

3. Configure provider details including NPI and Texas Medicaid ID (both required).

4. Generate 837P or 837I files as per your standard EDI workflow.

Prerequisites: Agencies must complete Trading Partner enrollment with TMHP, link providers (NPI + Texas Medicaid ID), and sign the EDI agreement before production submission.