Claiming Process

Learn about Maica's Claiming Process Generation logic.

Claiming Overview

In Maica, the Support at Home Claim Submission process enables you to generate and submit claim batches to Services Australia, retrieve the status of your claims, and automatically update your invoices and budgets based on the response received.

Purpose

The Support at Home Claim Submission process is designed to:

Generate a claim batch for submission to Services Australia via API.
Use a Quick Action to check the claim status after submission.
Update invoice and line item records based on the claim’s final status (e.g., paid).
Output Payment Request records in line with responses from Services Australia.

The Process

The process is linear and consists of the following stages:

Each stage of this process is covered in detail in this article.

To watch a full Video Demonstration of this process, click here.

1. Generate Claim Batch and Payment Requests

Purpose

Initiate a Support at Home Claim Batch by applying filter criteria to Invoice Line Item records. Records that meet the criteria will have Payment Request records generated and linked to a new Claim Batch.

User Action

The Generate Claim Batch quick action initiates the process, launching a modal for filter input.

UI Behaviour

The modal captures:

Start Date / End Date: Defines the date range for eligible Invoice Line Item records.
Service Provider: Multi-select lookup field.
Funding Type: Picklist field.

The modal provides flexibility to configure submission parameters for targeted claim batch generation.

Invoice Line Item Filtering Logic

Only Invoice Line Items where the related Invoice Claim Status is set to Open will be considered for inclusion in the batch.

Modal Input

Field

Notes

Start Date & End Date

maica_cc__Service_Date__c

The service date must fall within the selected range

Service Provider

maica_cc__Invoice__r.maica_cc__Service_Provider__c

Must match the provider(s) selected in the modal

Funding Type

maica_cc__Invoice__r.maica_cc__Funding_Type__c

Must match the funding type selected in the modal

Payment Request Field Mapping

The table below shows how fields from the Invoice Line Item are mapped into the newly created Payment Request:

Invoice Line Item Field

Payment Request Field

Id

maica_cc__Invoice_Line_Item__c

maica__Amount__c

maica_cc__Claimed_Amount__c

Process Outcome

Invoice Line Item records that meet the provided criteria are retrieved.
Retrieved Invoice Line Item records have a Payment Request record generated and linked to the Claim Batch via a Claim Batch Lookup.
This completes the initial generation of the claim batch.
The Generate Claim Batch quick action can be launched again at any time prior to submission of the claim to refresh or add additional Items to the existing Claim Batch

2. Upload Invoices and Invoice Line Items to Services Australia

Purpose

Upload the generated Claim Batch Invoice and Invoice Line Item records to Services Australia for processing.

User Action

User clicks the Submit Claim button in the Quick Action

A confirmation message is to be displayed to the user

Once done, the modal will update and alert the user that the Claim has been submitted.

System Action

Using the Invoices API, Maica:

Groups Invoice Line Item records by their parent Invoice.
For each parent Invoice:
- Posts a new Invoice record using the API POST method (mapping in the following Google Sheet)
- Upon successful creation, receives a Services Australia Invoice ID.
- Update the Invoice record in Maica with the following:
  - Services Australia Invoice ID = maica_cc__Invoice__c.maica_cc__Aged_Care_Invoice_ID__c
  - Invoice Closure Date (maica_cc__Invoice__c.maica_cc__Invoice_Closure_Date__c) = YESTERDAY
  - Invoice Claim Status (maica_cc__Invoice__c.maica_cc__Claim_Status__c) = SUBMITTED
- Posts all related Invoice Line Items (child records) using the retrieved Services Australia Invoice ID as the parent reference.
- Upon successful creation, receives a Services Australia Invoice Item ID.
  - Services Australia Invoice Item ID =maica_cc__Invoice_Line_Item__c.maica_cc__Aged_Care_Invoice_Item_ID__c

Record Updates in Maica

Invoice Object

Field

Update

Mapping

Aged Care Invoice ID

Set to Services Australia Invoice ID

maica_cc__Aged_Care_Invoice_ID__c

Invoice Closure Date

Set to YESTERDAY

maica_cc__Invoice_Closure_Date__c

Invoice Claim Status

Set to SUBMITTED

maica_cc__Claim_Status__c

Invoice Line Item Object

Field

Update

Mapping

Aged Care Invoice Item ID

Set to Services Australia Invoice Item ID

maica_cc__Aged_Care_Invoice_Item_ID__c

Data Model Alignment

The data model in Services Australia mirrors our own:

Invoice (parent record) directly maps to the local Invoice object.
Invoice Item (child record) directly maps to the local Invoice Line Item object.

Process Outcome

Invoice records are successfully submitted to Services Australia and marked as submitted in Maica.
Related Invoice Line Items are also posted and linked to their parent Invoices using the returned IDs.

3. Submit Claim Record to Services Australia

Purpose

Initiate the submission of the Claim Record associated with the batch to Services Australia.

User Action

No direct user interaction. This step is automatically initiated as part of the Submit Claim quick action previously selected.

System Action

Using the Claim API, the system:

Posts a Claim record populated with mapped values from the Claim Batch record / Maica Settings
Upon successful creation, receives a Services Australia Claim ID.
Uploads an array of associated Invoice IDs linked to the Claim, matching them to the submitted Invoices in Services Australia's system (mapping below)

Claim API Mapping – POST

Payload Field

Mapping

serviceProviderId

Taken from Maica Settings

invoices[].invoiceId

maica_cc__Invoice__c.maica_cc__Aged_Care_Invoice_ID__c

Claim API Mapping – RESPONSE

Payload Field

Mapping

claimId

maica_cc__Claim_Batch__c.maica_cc__Aged_Care_Claim_ID__c

status

maica_cc__Claim_Batch__c.maica_cc__Claim_Status__c

"CLAIMED"

Updates all associated Invoices' maica_cc__Claim_Status__c

Process Outcome

A Claim Record is created and linked to the Invoices in Services Australia.
The returned Claim ID is stored for visibility and future updates.

Next Step

Once the Claim is successfully submitted and its status is returned as Claimed, a new quick action called Check Claim Status becomes available on the Claim Batch record.

4. Check Claim Status

Purpose

Check the latest status of the submitted claim in Services Australia to determine if it has progressed to a final outcome such as ‘Paid’.

User Action

User selects the Check Claim Status quick action available on the Claim Batch record.

System Action

Using the Claim API, the system:

Retrieves the current status of the submitted Claim from Services Australia.
If the claim status has changed, updates the local Claim Batch and related records accordingly.
Returns additional attributes where applicable, such as:
- Updated Claim Status (e.g., BeingCalculated, PendingApproval, Approved)
- Claim Paid Date

Claim API → Claim Response – Field Mapping

Payload Field

Mapping

Notes

status

maica_cc__Claim_Status__c

- BeingCalculated = The claim is being calculated - PendingApproval = The claim is pending approval - Cancelled = The claim has been cancelled/rejected - Approved = The claim has been approved for payment - Paid = The claim is paid

paymentDate

maica_cc__Claim_Paid_Date__c

Only populated when maica_cc__Claim_Status__c = Approved

Process Outcome

The latest Claim Status and Claim Paid Date are updated on the Claim Batch record.
Triggers follow-up steps based on the claim’s updated status.

5. Retrieve Payment Statement and Update Claim Batch

Purpose

Capture final payment information from Services Australia after a claim has been marked as either Paid or Successful.

System Action

Once the Claim Batch status is updated to Paid, Maica automatically performs the following actions:

Initiates a callout to the Payment Statement API.
Retrieves relevant financial data from Services Australia, including:
- Payment Amount Summaries
- Claim Summaries
Maps and updates the retrieved values to the appropriate fields on the Claim Batch record.

Field Mapping

Payment Statement API → Claim Batch Mapping

Payload Field

Mapping

claimTotal

maica_cc__Claim_Total__c

totalPaid

maica_cc__Paid_Total__c

compensationReduction

maica_cc__Care_Recipient_Contribution_Amount__c

careRecipientIndividualContribution

maica_cc__Compensation_Reduction_Amount__c

heldoverPreviousPeriod

maica_cc__Previous_Held_Over_Payment_Amount__c

outstandingHeldover

maica_cc__Current_Held_Over_Payment_Amount__c

Process Outcome

The Claim Batch record is enriched with final payment figures.
Ensures all claim metrics and financial data are accurately captured and recorded.

6. Retrieve Updated Invoice Statuses

Purpose

Update the status of individual Invoice records associated with the Claim Batch.

System Action

Using the Invoices API, the system:
- Performs a callout using the Claim ID as the key to query all related Invoice records.
- Retrieves the latest status information for each Invoice:
  - Based on a match of maica_cc__Invoice__c.maica_cc__Aged_Care_Invoice_ID__c
- Updates the local Invoice records accordingly with any claim status changes returned.

Invoice API → Invoice Mapping

Payload Field

Mapping

status

maica_cc__Claim_Status__c

Process Outcome

Invoice records associated with the Claim Batch reflect their final processed status from Services Australia.

7. Retrieve Payment Item Details for Invoice Line Items

Purpose

Retrieve detailed payment information for each Invoice Line Item linked to the Claim Batch (via Payment Request records).

System Action

For each Invoice Line Item associated with the Claim Batch, the system performs a callout to the Payment Item Reporting API.
It retrieves specific payment data for the corresponding Payment Item in Services Australia’s system.
- This is done via the Invoice → Invoice Line Item relationship using the field maica_cc__Invoice_Line_Item__c.maica_cc__Aged_Care_Invoice_Item_ID__c.
- All Invoice records related to the Claim Batch are retrieved.
- The system then iterates through each related Invoice Line Item and matches on ItemId = maica_cc__Invoice_Line_Item__c.maica_cc__Aged_Care_Invoice_Item_ID__c.
Retrieved data is used to update Payment Request records in Maica.
Relevant claim and contribution fields are mapped and stored as shown below.

Payment Item Reporting API → Payment Request Mapping

Payload Field

Mapping

Notes

itemId

maica_cc__Invoice_Line_Item__r.maica_cc__Aged_Care_Invoice_Item_ID__c

claimSubmissionDate

maica_cc__Claim_Date__c

claimApprovedDate

N/A

paymentDate

maica_cc__Paid_Date__c

compensationReduction

maica_cc__Compensation_Reduction_Amount__c

individualContributionAmount

maica_cc__Care_Recipient_Contribution_Amount__c

paymentDetermination

maica_cc__Paid_Amount__c

(status)

maica_cc__Status__c

Set to PAID

Process Outcome

Each Invoice Line Item is updated with precise payment data reflecting actual amounts paid.
Enables granular financial tracking at the individual service delivery level.

8. Refresh Care Recipient Budgets

Purpose

As part of the finalisation of the claims process, this step ensures your care recipients’ budget data is refreshed and aligned with the completed and paid claim.

System Action

Triggered automatically once Step 7 completes successfully.
The system:
- Identifies all unique care recipient IDs from the claim items in the batch.
- For each unique care recipient ID:
  - Executes a call to the Budgets API endpoint.
  - Retrieves current budgets and creates or updates related Plan Budget and Entitlement records.
  - Only budgets where the End Date is within 60 days of today are included.

Outcome

You can now dispatch invoices for any remaining client contribution amounts that were not covered in the submitted claim.

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