Insurance Verification & Claims

Q: Can the automation handle claims that require pre-authorization?

Yes. The automation flags procedures that require pre-authorization based on coverage rules and alerts staff to submit pre-auth requests before treatment.

Q: What happens if a claim is denied?

The automation alerts staff immediately when a denial is received and logs the denial reason. Staff investigate, correct the submission if needed, and resubmit; the automation then monitors the resubmitted claim status.

Q: Will the automation work with our existing patient management system?

The automation integrates with common dental practice management systems and spreadsheets. During setup, we confirm your system is compatible and establish secure data connections so patient and treatment information flows automatically.

Q: How does the automation handle partial payments or payment adjustments?

The automation matches incoming payments to claims and flags partial payments or adjustments for staff review. Staff confirm the adjustment reason (e.g., contractual write-off) and the automation updates the patient account and accounting.

Automated eligibility checks and claim submissions free your front desk from hours of hold music and manual data entry.

1.7k hrs

Manual time identified

Companies have mapped

Map This Automation

About This Automation

Insurance verification and claims processing consume significant staff time across multiple manual steps: eligibility checks, documentation, submission, and status tracking. Manual processes introduce errors, delays, and high claim denial rates that impact cash flow.

Automation queries insurance systems in real time, compiles and submits claims automatically, monitors status daily, and alerts staff to denials or payments. The result is faster claim submission, fewer denials, and reduced administrative overhead.

Key features:

Query insurance payer systems in real time to retrieve eligibility and coverage details

Compare planned treatment against verified coverage and flag pre-authorization needs

Compile claim data from patient records and submit claims automatically via API or portal

Monitor claim status daily and alert staff to denials, rejections, or payment receipt

Match incoming payments to claims and update patient account records automatically

Track appeal submissions and resubmissions to reduce manual follow-up

Data insights How it works Apps used What you get FAQ

Top friction points when done manually

The issues teams report most often with this process

#	Friction point	Companies Report This
1	Insurance verification phone calls Staff spend 8-15 minutes per call navigating automated menus and waiting on hold, with incomplete or unclear responses.	80%
2	Manual claim data re-entry Treatment codes, patient demographics, and provider information are re-entered from multiple sources into claim forms.	67%
3	Daily claim status checks Staff manually call payers or log into portals daily to check status, with results recorded in spreadsheets.	53%
4	Claim denial investigation and resubmission Denials require manual investigation, correction, and resubmission, often delaying payment by 1-2 weeks.	40%
5	Payment matching and reconciliation Received payments are manually matched to claims and recorded in accounting software, with discrepancies resolved by hand.	26%

Disclaimer

Automation readiness

How well-suited this process is for automation

Process Pain Score™

8.8/ 10

AI Fit Rating™

8.6/ 10

Automation Lift Index™

8.4/ 10

Hidden Overhead™

7.1/ 10

How The Automation Works

The full workflow, from trigger to completion.

1. Patient appointment scheduledtrigger

Trigger fires when a new appointment is created or insurance details are updated in the patient management system.

2. Extract patient and insurance data

Reads patient demographics and insurance card details from the source system and prepares them for eligibility lookup.

3. Query eligibility via API

Automation sends eligibility request to insurance payer API or clearinghouse and retrieves real-time coverage, deductible, and co-pay data.

4. Log eligibility

Eligibility results are automatically written to a shared log with timestamp and payer response for audit and review.

5. Flag coverage gaps for review

Analyzes coverage against planned treatment and flags any exclusions, pre-authorization needs, or missing information for staff review.

6. Prepare and submit claim

Automation compiles treatment codes, patient data, and provider information into claim format and submits directly to payer via API or secure portal.

7. Send confirmation

Automation notifies billing staff that claim has been submitted and provides tracking reference number.

8. Monitor claim status automatically

Automation polls payer system daily for claim status updates and alerts staff if claim is denied or payment is received.

Most popular tool stack used

— the complete tool combinations companies use

52% of companies

28% of companies

15% of companies

Disclaimer

What you get when you map this process

Everything you need to understand, plan, and build your automation.

ROI and business case

What this process costs today and what changes once it's automated.

Launch schedule

What gets built, in what order, and what success looks like once it's live.

Process runbook

How the automation runs day to day, including exceptions and human decision points.

Developer handover pack

Full build spec, logic, and configuration — ready to hand off without a briefing call.

Integration and connections guide

Every tool connection, credential, and data mapping the build needs.

Test and QA plan

20 hrsIdentified

4Mapped

View

Frequently asked questions

Everything you need to know before mapping this process.

What happens if an insurance company is not in the automation system?

The automation handles major national and regional payers via API or portal integration. For smaller or regional insurers not yet integrated, staff receive an alert to verify eligibility manually, and the claim is submitted once coverage.

Can the automation handle claims that require pre-authorization?

What happens if a claim is denied?

Will the automation work with our existing patient management system?

How does the automation handle partial payments or payment adjustments?

View more FAQs

Process pain:8.8/10

Mapped by:30 Companies

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Page updated 10 August 2026