What Is the Revenue Cycle?
The revenue cycle is the end-to-end process of converting clinical services into collected revenue. For ABA practices, this cycle typically takes 30–90 days from date of service to final payment. Understanding and optimizing each stage is the foundation of financial health for an ABA practice.
Stage 1 — Eligibility Verification
Before the first appointment, verify the patient's insurance coverage:
- Confirm active coverage and effective date
- Verify ABA is a covered benefit and identify any exclusions
- Identify deductible, out-of-pocket maximum, and copay/coinsurance
- Confirm whether a referral or prior authorization is required
- Run real-time eligibility checks (270/271 EDI transaction) through your clearinghouse
Onvelas: Use Billing → Eligibility to run real-time eligibility checks for any patient before service.
Stage 2 — Prior Authorization
Most commercial payers and all Medicaid programs require prior authorization for ABA services:
- Submit behavioral assessment (97151) first; use the assessment report to support the treatment authorization request
- Obtain written authorization with auth number, approved codes, units, and effective dates
- Enter the authorization into Onvelas under Patients → Authorizations before the first treatment session
- Never provide services without confirmed authorization — retroactive approval is rarely granted
Stage 3 — Service Delivery and Documentation
The clinical team delivers services and creates documentation:
- Session notes must be completed and co-signed (if required) within 24 hours of service
- Notes must support the billed CPT code — document start time, end time, activities, progress on goals
- BCBA must document supervision contacts per BACB requirements
- Caregiver training sessions require documentation of caregiver attendance and training content
Stage 4 — Charge Capture and Claim Creation
Billing converts completed sessions into billable claims:
- Match service dates to authorized sessions — verify units used vs. units remaining in the authorization
- Select the correct CPT code based on who rendered and what type of service
- Apply the correct modifiers (HM, HN, HO) and place of service code
- Verify diagnosis codes and select the correct ICD-10 pointer for each line item
- In Onvelas: Billing → New Claim or generate claim from a session via Scheduling
Stage 5 — Claim Scrubbing and Submission
Before submission, claims pass through automated scrubbing:
- Check for missing required fields (NPI, tax ID, member ID, billing address)
- Validate that the auth number is present for services requiring authorization
- Confirm units don't exceed authorized amounts
- Verify no duplicate claim exists for the same patient, date, and code
- Submit electronically via clearinghouse (ClaimMD) — paper claims delay payment by 2–3 weeks
Stage 6 — Claim Adjudication (Payer Processing)
After submission, the payer adjudicates the claim:
- Days 1–3: Clearinghouse validates and transmits to payer; 999 acknowledgment received
- Days 3–7: Payer validates claim format (277CA acknowledgment)
- Days 7–30: Payer adjudicates — approves, partially pays, or denies
- Days 15–45: ERA (835) or EOB received with payment details
Stage 7 — Payment Posting and ERA Reconciliation
When payment arrives:
- Post the ERA payment to the correct claim in Onvelas (Billing → Deposits)
- Apply contractual adjustments (CO-45) as write-offs
- Identify patient responsibility (PR codes) and move to patient balance
- Reconcile the ERA total against the bank deposit amount
- Flag any claim lines that were denied or partially paid for follow-up
Stage 8 — Denial Management and AR Follow-Up
Denied and unpaid claims require active management:
- Identify the CARC code and root cause of each denial
- Correct and resubmit correctable claims within 5 business days
- File formal appeals for medical necessity or authorization denials within 60 days
- Track all unpaid claims older than 30 days in the AR Follow-Up queue
- Goal: Keep accounts receivable (AR) days under 45; monitor the percentage of AR over 120 days
Stage 9 — Patient Collections
After insurance adjudication, collect patient responsibility:
- Generate patient statements promptly after ERA posting
- Offer payment plans for large balances
- Follow up on outstanding patient balances at 30 and 60 days
- Know your state's rules on patient collections and small balance write-off thresholds
Key Metrics to Monitor
| Metric | Target |
|---|---|
| Days in AR | < 45 days |
| Clean claim rate | > 95% |
| First-pass acceptance rate | > 90% |
| Collection rate (net) | > 96% |
| AR over 120 days | < 15% of total AR |
| Denial rate | < 5% |