# Claiming Process

## 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:

1. [**Generate Claim Batch and Payment Requests**](#id-1.-generate-claim-batch-and-payment-requests)
2. [**Upload Invoices and Invoice Line Items** to Services Australia](#id-2.-upload-invoices-and-invoice-line-items-to-services-australia)
3. [**Submit Claim Record** to Services Australia](#id-3.-submit-claim-record-to-services-australia)
4. [**Use Quick Action (QA)** to retrieve Claim Status](#id-4.-check-claim-status)
5. [**Retrieve Payment Statement** and update Claim Batch](#id-5.-retrieve-payment-statement-and-update-claim-batch)
6. [**Retrieve Updated Invoice Statuses**](#id-6.-retrieve-updated-invoice-statuses)
7. [**Retrieve Payment Item Details** for Invoice Line Items](#id-7.-retrieve-payment-item-details-for-invoice-line-items)
8. [**Refresh Care Recipient Budget data**](#id-8.-refresh-care-recipient-budgets)

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

{% hint style="success" %}
To watch a full Video Demonstration of this process, click [here](https://app.gitbook.com/s/hehRshYIRk6XUlay9L3b/support-at-home/claiming-overview#video-demonstration). 
{% endhint %}

***

### 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.
* **Include Failed Items** – Checkbox allowing inclusion of invoice line items with a `Claim Status` of *Submission Failed* if they fall within the selected date range.
* **Service Provider ID**: This selection determines **which invoices are eligible** for inclusion in the batch. 

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

<figure><img src="https://293583916-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2F9selzjEx6KX7RYEawAVr%2Fuploads%2FW7YZ29LQHgwgx9Z3ZpOk%2Fimage.png?alt=media&#x26;token=9d2b3ffa-7e77-4d84-9e88-38ce4674ea27" alt=""><figcaption></figcaption></figure>

***

#### Service Provider ID Selection&#x20;

When generating a Claim Batch for **Support at Home**, claims are created under a specific **Service Provider ID**. This ensures invoices are grouped and submitted in the correct provider context.

During the **Generate Claim** process, you must select a **Service Provider ID**.

* The available Service Provider IDs are populated from those synced in **Support at Home Settings**.
* Only one Service Provider ID can be selected per Claim Batch.
* If no Service Provider IDs are available, you must first run [**Sync Service Providers**](https://knowledge.maica.com.au/maica-knowledge-base/maica-administration-guide/support-at-home/care-management-budget-sync) in Support at Home Settings.

When a Service Provider ID is selected:

* Only invoices where the related Participant (Contact) is associated with the same **Service Provider ID** are retrieved.
* Invoices associated with Participants under other Service Provider IDs are excluded.

{% hint style="info" %}
The selected Service Provider ID is stored on the Claim Batch record and is used for audit, reporting, and downstream processing.
{% endhint %}

{% hint style="info" %}
If no eligible invoices exist for the selected Service Provider ID and date range, the Claim Batch is generated without invoices and a message is shown indicating that no invoices were available.
{% endhint %}

***

#### Invoice Line Item Filtering Logic

Only `Invoice Line Item` records where the related **Invoice Claim Status** is set to `Open`, `maica__Invoice_Line_Item__c`.`maica__Exclude__c` = **TRUE,** or (if the **Include Failed Items** checkbox is selected) `Submission Failed`, will be considered for inclusion in the batch.

<table><thead><tr><th width="191.42620849609375">Modal Input</th><th>Field</th><th>Notes</th></tr></thead><tbody><tr><td>Start Date &#x26; End Date</td><td><code>maica_cc__Service_Date__c</code></td><td>The service date must fall within the selected range</td></tr><tr><td>Service Provider</td><td><code>maica_cc__Invoice__r.maica_cc__Service_Provider__c</code></td><td>Must match the provider(s) selected in the modal</td></tr><tr><td>Funding Type</td><td><code>maica_cc__Invoice__r.maica_cc__Funding_Type__c</code></td><td>Must match the funding type selected in the modal</td></tr><tr><td>Include Failed Items</td><td>n/a</td><td>When selected, includes records where the related claim has <code>Claim Status = Submission Failed</code> within the defined service dates.</td></tr></tbody></table>

***

#### 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.&#x20;

***

#### 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](https://docs.google.com/spreadsheets/d/1IDFI-nCkVysqpB1LA9Zclcl2nTIyn_JyHWBXM9I5Z-o/edit?usp=sharing))
  * 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
    * `Original Claim Date` → `maica_cc__Invoice__c.maica_cc__Original_Claim_Date__c` = *Date Submitted*
    * `Claim Submission Error Details` → populated if the submission fails or partially
  * 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`

{% hint style="info" %}
Validation exists to control when Invoices and Invoice Line Items can be modified based on `Claim Status`. Invoices are now editable **only** when the `Claim Status` is **Open** or **Submission Failed**.

**Key behaviours:**

* Invoice Line Items can only be added or re-related when the `Invoice` `Claim Status` is **Open** or **Submission Failed**.
* Once an Invoice moves to **Submitted, Held, Deleted, Claimed, or Completed**, its financial structure is locked.
* Invoice totals (line item count and total amount) cannot be changed in locked statuses.
* Non-financial updates to existing Invoice Line Items (such as Descriptions) remain permitted.

**Why this matters:**

This ensures financial accuracy and claim integrity by preventing submitted or processed Invoices from being altered, while still allowing correction and rework when a submission fails. It reduces the risk of accidental claim discrepancies and supports a controlled, auditable claiming lifecycle.
{% endhint %}

***

#### 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`                   |
| Original Claim Date            | Set to date/time of submission                  | `maica_cc__Original_Claim_Date__c`            |
| Claim Submission Error Details | Set if Services Australia returns error details | `maica_cc__Claim_Submission_Error_Details__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.
* If any submission errors are returned, they are captured in `Claim Submission Error Details` for troubleshooting.
* All subsequent claim processing steps reference the stored `Original Claim Date` for accurate reporting.

***

### 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&#x20;

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)

& also:&#x20;

* Updates all related **Payment Requests** to reflect the outcome of the submission.

***

#### 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.
* A **financial summary for a Claim Batch** is displayed&#x20;

***

#### Additionally

As part of the Claim submission process, Maica updates all related **Payment Requests** to reflect the outcome of the submission.

**1. Set Claim Date**

* When `Payment Request` records are submitted as part of a `Claim Batch`:
  * Always populate the `Claim Date` field (`maica__Claim_Date__c`) with the **date (day only)** of the submission event

**2. Manage Status Updates**

* `Payment Request` → `Status` **(**`maica__Status__c`**)** as follows:
  * **If successfully submitted for claiming**&#x20;
    * Set `Status` = `Awaiting Approval`
      * API Value = `7`
  * **If submission fails or is rejected (validation errors, Service Australia logic failure, etc.)**&#x20;
    * `Status` = `Failed`
      * API Value = `Failed`

This ensures users can immediately distinguish between successfully submitted and failed requests directly from the `Claim Batch` record.

#### 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**

{% hint style="info" %}
There is validation within the `Claim Status` field on the `Claim Batch` object to enforce a forward-only workflow.

**Key behaviours:**

* `Claim Status` can only progress forward through its lifecycle.
* Backward status changes are no longer permitted.
* **Cancelled** and **Completed** are now treated as final states and cannot be changed once set.

**Why this matters:** This protects submitted and processed claims from accidental modification or re-claiming, improving data integrity and compliance with the Aged Care claiming process.\
\
To see the Validation Rule detail and logic, refer to the expandable below.&#x20;
{% endhint %}

<details>

<summary>Claim Status Validtion Rule</summary>

<table data-header-hidden><thead><tr><th width="119.3046875"></th><th></th></tr></thead><tbody><tr><td><strong>Rule Name</strong></td><td><code>Claim_Status_Management</code></td></tr><tr><td><strong>Description</strong></td><td><p>Prevents backward changes to the Claim Status on an Aged Care Claim Batch.</p><p>The Claim Status may only progress forward through its defined lifecycle. Once the status is set to <strong>Cancelled</strong> or <strong>Completed</strong>, it is treated as a final state and cannot be changed.</p><p>This rule helps protect submitted and processed claims from being modified or re-claimed after key workflow stages have been reached.</p></td></tr><tr><td><strong>Help Text</strong></td><td>Claim Status cannot be moved backwards. Cancelled and Completed are final states and cannot be changed.</td></tr></tbody></table>

</details>

***

#### Claim API → Claim Response – Field Mapping

<table><thead><tr><th width="133.2318115234375">Payload Field</th><th width="277.7430419921875">Mapping</th><th>Notes</th></tr></thead><tbody><tr><td><code>status</code></td><td><code>maica_cc__Claim_Status__c</code></td><td>- <code>BeingCalculated</code> = The claim is being calculated <br>- <code>PendingApproval</code> = The claim is pending approval <br>- <code>Cancelled</code> = The claim has been cancelled/rejected <br>- <code>Approved</code> = The claim has been approved for payment <br>- <code>Completed</code> = The claim is paid</td></tr><tr><td><code>paymentDate</code></td><td><code>maica_cc__Claim_Paid_Date__c</code></td><td>Only populated when <code>maica_cc__Claim_Status__c = Approved</code></td></tr></tbody></table>

***

#### 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 **Completed** 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**

<table><thead><tr><th width="305.0069580078125">Payload Field</th><th>Mapping</th></tr></thead><tbody><tr><td><code>claimTotal</code></td><td><code>maica_cc__Claim_Total__c</code></td></tr><tr><td><code>totalPaid</code></td><td><code>maica_cc__Paid_Total__c</code></td></tr><tr><td><code>compensationReduction</code></td><td><code>maica_cc__Care_Recipient_Contribution_Amount__c</code></td></tr><tr><td><code>careRecipientIndividualContribution</code></td><td><code>maica_cc__Compensation_Reduction_Amount__c</code></td></tr><tr><td><code>heldoverPreviousPeriod</code></td><td><code>maica_cc__Previous_Held_Over_Payment_Amount__c</code></td></tr><tr><td><code>outstandingHeldover</code></td><td><code>maica_cc__Current_Held_Over_Payment_Amount__c</code></td></tr></tbody></table>

#### 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.
* The `Aged Care Reference` (`maica_cc__Aged_Care_Reference__c`) is now included in the Payment Item mapping for clearer traceability between claim items and their corresponding Services Australia reference.
* Relevant claim and contribution fields are mapped and stored as shown below.

#### Payment Item Reporting API → Payment Request Mapping

<table><thead><tr><th width="283.51654052734375">Payload Field</th><th width="330.4539794921875">Mapping</th><th>Notes</th></tr></thead><tbody><tr><td><code>itemId</code></td><td><code>maica_cc__Invoice_Line_Item__r</code>.<code>maica_cc__Aged_Care_Invoice_Item_ID__c</code></td><td></td></tr><tr><td><code>claimSubmissionDate</code></td><td><code>maica_cc__Claim_Date__c</code></td><td></td></tr><tr><td><code>claimApprovedDate</code></td><td>N/A</td><td></td></tr><tr><td><code>paymentDate</code></td><td><code>maica_cc__Paid_Date__c</code></td><td></td></tr><tr><td><code>compensationReduction</code></td><td><code>maica_cc__Compensation_Reduction_Amount__c</code></td><td></td></tr><tr><td><code>individualContributionAmount</code></td><td><code>maica_cc__Care_Recipient_Contribution_Amount__c</code></td><td></td></tr><tr><td><code>paymentDetermination</code></td><td><code>maica_cc__Paid_Amount__c</code></td><td></td></tr><tr><td><em>(status)</em></td><td><code>maica_cc__Status__c</code></td><td>Set to <strong>PAID</strong></td></tr><tr><td><code>agedCareReference</code></td><td><code>maica_cc__Aged_Care_Reference__c</code></td><td>Services Australia’s reference ID for cross-system validation.</td></tr></tbody></table>

#### Process Outcome

* Each `Invoice Line Item` is updated with precise payment data reflecting actual amounts paid.
* The inclusion of the `Aged Care Reference` field ensures each Payment Request is traceable to its corresponding record in Services Australia’s system.
* 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.

{% hint style="success" %}
To download the full schema, with all mappings and validations for this process, [click here](https://docs.google.com/spreadsheets/d/1Uy_XUpFUAvG-8CpkdLFx_Aa-Hi0TPRiSS1zufD48oig/edit?usp=sharing).&#x20;
{% endhint %}

<div data-full-width="true"><figure><img src="https://293583916-files.gitbook.io/~/files/v0/b/gitbook-x-prod.appspot.com/o/spaces%2F9selzjEx6KX7RYEawAVr%2Fuploads%2F2MBi9iyHLwpnXNVQoqf1%2FFlow.png?alt=media&#x26;token=3bbfe50b-18e4-42fd-85bb-f4239e498f37" alt="" width="409"><figcaption></figcaption></figure></div>