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.
The full workflow, from trigger to completion.
Trigger fires when a new appointment is created or insurance details are updated in the patient management system.
Reads patient demographics and insurance card details from the source system and prepares them for eligibility lookup.
Automation sends eligibility request to insurance payer API or clearinghouse and retrieves real-time coverage, deductible, and co-pay data.
Eligibility results are automatically written to a shared log with timestamp and payer response for audit and review.
Analyzes coverage against planned treatment and flags any exclusions, pre-authorization needs, or missing information for staff review.
Automation compiles treatment codes, patient data, and provider information into claim format and submits directly to payer via API or secure portal.
Automation notifies billing staff that claim has been submitted and provides tracking reference number.
Automation polls payer system daily for claim status updates and alerts staff if claim is denied or payment is received.
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