School based Medicaid billing where every claim leaves with its five proofs, and no eligible session goes unbilled
Every Medicaid claim leaves with its five proofs, and no eligible session goes unbilled.
See one case, screen by screen ↓School-Based Medicaid Billing & Claiming checks every therapy and nursing session before a district bills Medicaid, so school based Medicaid billing leaves with five proofs per claim. Agents check enrollment, IDEA parental consent and this year's notice, the IEP order, the provider's credential and the session note, find the proof that clears a stop, and find eligible sessions nobody billed before the 12-month filing limit. The Medicaid claims coordinator approves each weekly batch, and the business office releases it.
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School based Medicaid billing pays a district only when five records agree for each session: the student was enrolled in Medicaid that day, the family gave the one-time written consent and got this year's notice, the IEP ordered that service at that frequency and duration, the provider was licensed (and an assistant supervised), and the note has every element the state requires. Today the Medicaid claims coordinator exports the provider service log, the IEP system's service pages and the state's monthly enrollment file every Monday and matches them in a spreadsheet by name and birth date.
She checks consent dates in scanned IEP packets, emails HR about licenses that look expired and emails providers about notes missing a signature or a time, and most fixes arrive after the cut. A license renewal HR never keyed in stops a whole caseload. Late paper logs, the health office's nursing log and summer sessions go unbilled until the 12-month filing limit passes. The business office sees the money weeks later in the remittance and cannot tie it to the sessions, and in an audit each claim's evidence is rebuilt from five systems.
Estimated split of one weekly batch of about 2,700 sessions, by hand and with the solution, in hours.
An agent at each of five gates, each checked by another; the claims coordinator approves, the business office releases.
Tuesday, October 20, 2026, 9:05 a.m., at Marlow Bay Unified School District. The week 42 batch (October 12–16) was cut Monday at 11:00 p.m., and the agents ran overnight. Lorena Bautista, the Medicaid claims coordinator, opens the checkpoint.
The week's sessions for 1,968 students from 180 providers, worth $198,340 at the state fee schedule, move as dots through five gates: enrolled in Medicaid, parental consent, IEP order, provider credential and session note. Each gate shows its agent, how many passed and how many it stopped, and stopped sessions pile below the gate with the reasons in plain words. At the right end: 2,529 sessions ready to bill, $181,548.
46 of 213 stops already have their proof. Clearing them adds $4,692.
Lorena opens the credential pile: 46 occupational therapy sessions by Hannah Kepler, OTR/L, for 14 students, October 1–16. HR shows her license expired September 30. The agent searched her HR file, found the renewal certificate uploaded October 2 and dated September 28, valid through September 30, 2028, and confirmed it on the state license lookup. A second agent, the Documentation agent, checked the gate's passes.
Proposed: clear 46 sessions, and ask HR to update the date · confidence 0.98, above the 0.95 threshold.
Lorena clears the 46 sessions with the certificate cited and a reason code. The dots move on, and ready to bill rises to 2,575 sessions, $186,240: 93.9% of the week, for 1,912 students from 174 providers. HR gets a task to fix the date in the source record, so the same stop does not come back next week.
The 167 sessions still stopped sit in 17 items, filtered by gate: enrolled 54, consent 27, IEP order 43, credential 5, note 38. Each item has its owner, its filing clock and the agent's proposed next step, such as "Coverage ended Sep 30" for 31 sessions of 9 students or "More sessions than the IEP orders" for 17. She can ask providers, hold or write off in bulk, each with a reason code.
She opens a claim that passed: Jordan M., grade 3, Harborview Elementary, speech-language therapy, Wednesday October 14, 9:30–10:00 a.m., with Marisol Duarte, CCC-SLP, $88. Enrolled October 1–31; consent signed September 22, 2024, and this year's notice delivered September 9, 2026; the IEP orders 2 × 30 minutes a week; the license is active to March 31, 2028; the note has 7 of 7 elements. Each proof opens its source.
Marisol has 58 students across two elementary schools. Her view lists 15 notes missing one thing each: 6 need her signature and 9 need the student's response, with her own trial counts beside them. She adds the response and signs one note, or six after review. Her view shows no Medicaid status and no dollar values, so billing never shapes a service decision.
The Documentation agent never writes or signs a note. It asks the provider exactly what is missing.
Nineteen sessions wait at the consent gate for three students with no consent to bill Medicaid on file. The Consent agent drafted each request from the IDEA consent elements: Spanish for Camila R. and Mateo G., Vietnamese for Bao N., each with the English beside it. Bao's 5 physical therapy sessions ($520) are held; the Vietnamese draft scores 0.93 translation confidence. Lorena approves, and the case manager, Peter Vo, co-signs and sends.
Drafted by the Consent agent · approved by the coordinator · sent by the case manager. The sessions stay held until consent is signed.
The Recovery agent searched late provider logs, the health office's nursing log and summer logs and found 214 eligible sessions never billed, worth $15,408. The oldest, Ava L.'s speech session of November 3, 2025, reaches the 12-month limit in 14 days, and 38 are within 30 days. Added to next week's batch, they still pass all five gates.
The batch shows each service at the state fee schedule, from speech-language individual (756 sessions, $66,528) to transportation (100 trips, $2,400), with the five gates' summary. The agents re-checked a 2% sample end to end from the source records, and 52 of 52 agree. Lorena attests to what she checked and approves 2,575 sessions, $186,240.
Kevin sees the approved batch and the rule that the person who approved it cannot release it. He releases it: the claim file is built (837P, 2,575 lines, 174 rendering providers), the state Medicaid billing portal accepts 2,575 of 2,575, and the ERP books the receivable. The remittance is expected about October 26.
The approver never releases.
The same week of sessions, seen by the people who claim it, deliver it, release it and audit it: what it looked like, and what it looks like now.
An agent at each of five gates, each checked by another; the claims coordinator approves, the business office releases.
Matches each session's student to the state's monthly Medicaid enrollment file for the date of service, and runs the daily eligibility check for any session not matched.
Finds the one-time written consent and this school year's notice, and drafts consent requests with the required elements in the home language, the English beside.
Matches each session to the IEP's service, frequency, duration and dates, and checks the signed prescription for occupational and physical therapy.
Checks each provider's license, certification and supervision against the date of service in the HR record, and finds renewals in the HR file and on the state license lookup.
Checks each session note against the state's seven required elements: date, start and end time, service and code, individual or group size, the student's response, and the provider's signature and credential.
Searches late provider logs, the health office's nursing log and summer sessions for eligible sessions never billed, sorted by days left to the 12-month filing limit.
Sends and reminds random moment time study moments, and checks each answer has enough detail to be coded.
Builds the recoupment audit pack for a batch: five proofs per claim, both approvals, the agents' versions and the access log, then redacts other students and seals it.
Approve and release. The agents propose; a named person decides.
Ask in plain words, or say what to follow up. Every answer points to the record or rule it rests on, and opens the screen where you can act.
Why did 46 sessions stop at the credential gate?
HR shows Hannah Kepler's state OT license expiring Sep 30, 2026, so her 46 sessions after that date stopped. Her HR file holds the renewal certificate, dated Sep 28, valid to Sep 30, 2028, and the state lookup shows her license active. Clearing them adds $4,692.
Which unbilled sessions are closest to the filing limit?
The Recovery agent found 214 eligible sessions never billed ($15,408). The closest are Ava L.'s speech session of Nov 3, 2025 (14 days left), Diego M.'s nursing session of Nov 5, 2025 (16) and Hazel B.'s speech session of Nov 10, 2025 (21). 38 are within 30 days. Added to next week's batch, they still pass all five gates.
Is consent on file for Bao N.?
No. Bao N.'s Medicaid began on Oct 1, and there is no one-time consent in the IEP system. IDEA requires it before the first claim. The Consent agent drafted the request in Vietnamese with the English beside it, at 0.93 translation confidence. You approve it, and Peter Vo, his case manager, sends it. His 5 physical therapy sessions ($520) are held until then.
Build the audit pack for batch W42
Building it now: each claim with its enrollment proof, consent and this year's notice, IEP order and prescription, the provider's credential on the date, the signed note, both approvals, the agents' versions and the access log. Other students' names are redacted. Every pack is logged.
13 screens from the working solution, on its sample data. Pick one to see it large.
The rules and clocks every session is checked against are settings, changed by the systems administrator, and every change makes a new version on the audit trail.
| Setting | Default | Choose from |
|---|---|---|
| Cut the weekly batch | Monday, 11:00 p.m. | Monday 11:00 p.m., Friday 6:00 p.m. or every two weeks; the five gates run right after the cut |
| Sample re-check before approval | 2% of the batch | A percentage drawn at random and re-checked end to end from the source records |
| Warn before the 12-month filing limit | 30 days before | Any number of days, with warnings also at 60 and 14 days (42 CFR 447.45(d)) |
| Note fixes due | 5 school days | School days from the Documentation agent's ask |
| Follow up an unsigned consent request | 10 school days | School days, then the case manager calls the family |
| Remind a time study participant | 24 hours after | Hours after the moment is sent; moments are due in 2 business days under the state rule |
| Propose only above | 0.95 for most agents | 0.85, 0.90, 0.95 or 1.00, per agent |
| Keep claim records | 6 years | 6, 7 or 10 years after the claim is paid, then destroyed with a log entry |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample district data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (HHS Office of Inspector General audits of state school-based Medicaid programs: September 2026, an estimated $454.9 million that may have been improperly claimed; 2024, $551.4 million improperly claimed). Rule context: IDEA, 34 CFR 300.154(d) and 300.622; FERPA, 34 CFR Part 99; 42 CFR 447.45(d) on the 12-month filing limit. The district, schools, students, families and people named on this page are fictional — characters and sample data in the working solution.
School-Based Medicaid Billing & Claiming checks every therapy and nursing session before a district bills Medicaid, so school based Medicaid billing leaves with five proofs per claim. Agents check enrollment, IDEA parental consent and this year's notice, the IEP order, the provider's credential and the session note, find the proof that clears a stop, and find eligible sessions nobody billed before the 12-month filing limit. The Medicaid claims coordinator approves each weekly batch, and the business office releases it.
Providers log sessions as they do today. After the weekly cut, five agents check each session at five gates, and a second agent re-checks every pass from a different record. The coordinator clears or holds what stopped, approves the batch after a 2% sample re-check, and the business office releases the claim file to the state Medicaid billing portal.
Yes. The Consent agent looks for the one-time written consent and this school year's notice that 34 CFR 300.154(d) requires. Where consent is missing, it drafts the request in the family's home language with the English beside it; the coordinator approves and the case manager sends. Those sessions stay held until consent is signed.
Yes. The Recovery agent searches late provider logs, the health office's nursing log and summer sessions and sorts what it finds by days left to the 12-month limit. In the sample district it found 214 eligible sessions worth $15,408, 38 of them within 30 days. Recovered sessions still pass all five gates.
Yes. The Time study agent sends and reminds moments, tracks the response rate against the state's rule and returns answers such as "Worked with students." to the participant for codable detail. It never answers or codes a moment; the state's coders do.
Every claim already carries its five proofs, both approvals, the agents' versions and the access log. The Audit pack agent builds the pack for a batch, redacts other students and seals it, and every pack is logged. The auditor can read everything and change nothing.
Yes. Agents check, find and draft; people decide. The provider signs the note, the coordinator clears every stop with a reason code and approves consent drafts and batches, the case manager sends consent requests, and the business office releases. The person who approves a batch cannot release it.
The Agentic Solution Engine builds and deploys it from your requirements and documents: your state's school-based services manual and fee schedule, your consent forms and a sample of past sessions and IEP orders. It goes live once every quality gate has passed. We will walk you through it on your own records first.
Every draft IEP read against the rule before the meeting, not a sample after it.
1-min demoSpecial Education Due Process & State ComplaintsChronologies in hours, not weeks, with every allegation tied to the page that proves it.
1-min demoSection 504 Plan ManagementEvery teacher sees the plan, and every test is checked before it starts.
1-min demoWe'll run School-Based Medicaid Billing & Claiming on a sample of your own past sessions, IEP orders and your state's billing rules.