By the time a denial lands in the A/R aging report, the failure has already happened — usually days or weeks earlier, in a system that wasn't talking to the one downstream.
We're building the system that catches it in the moment, not in the report.
Care reimbursement failures often happen upstream of billing — when services are scheduled outside authorization limits, EVV records do not match claims, eligibility changes are missed, documentation is incomplete, or payer-channel rules are applied incorrectly.
Reduces preventable denials, delayed payments, write-offs, and billing rework.
Stops a non-reimbursable visit from being booked in the first place.
A coordinator books a 4-hour visit against a 28-hour weekly cap that's already at 26. EVV will record it. The claim will deny.
The caregiver clocks a visit in EVV, but the claim is submitted with more units than the verified visit duration supports, or with a service/date/member profile that does not match the EVV record. The care happened; the payable claim line does not reconcile.
Member moved from one MCO to another on the 1st of the month. Visits delivered on the 2nd and 3rd of the month were submitted to the old plan. The new plan won't take a retro claim.
The visit occurred, but the payable record is incomplete: the plan of care/order is missing or unsigned, the aide task record does not support the service, or the required RN supervisory visit is not documented. The result is denial, delayed resubmission, or audit recoupment.
A T1019 personal-care visit is submitted using the PCA claim profile, but the member is enrolled under an ABI/MFP waiver or managed-care arrangement. The service occurred, but the claim uses the wrong funding stream, authorization path, or modifier set.
The scheduled visit, the EVV record, and the claim line are reconciled against each other and against the payer's tolerance rules. Mismatches in time, service code, modifier, member ID, or rendering provider are surfaced before the 837 is built — with the specific edit that needs to happen.
MoonbaCare runs 270/271 eligibility checks on a schedule per member, watches for plan changes between visit date and bill date, and flags any visit whose member moved plans inside the bill window.
Caregivers and coordinators talk in one HIPAA-safe channel — tied to the member, the visit, and the care plan. No personal phone numbers, no texting PHI through consumer apps, no lost context.
Sequenced against pilot learnings. Subject to change as we go.
MoonbaCare is being designed as a system of intelligence, not just a systems of records. That choice dictates the integrations, the data model, and the security posture below.
Certifications and audits below are stated intent during pilot. Formal attestations follow production deployment.
Operators, engineers, and payer veterans who have lived the reimbursement problem from every side.
Leads MoonbaCare's product, AI, and domain strategy. Focused on turning complex HCBS workflows — authorization, EVV, documentation, claims, and reimbursement — into practical systems that reduce errors before they become denials.
If reimbursement leakage is no longer ignorable at your agency, or you work on this problem from another angle, we'd like to hear from you.