Insurance, Billing & Claims

Q: Do we still need staff to review claims before they are submitted?

No. The automation handles eligibility verification, formatting, and submission without manual review.

Q: Will this work with all of our insurance payers?

The automation integrates with payers that offer API access or electronic submission. Smaller or regional payers may require manual submission, which the system flags for your team.

Q: How does the system handle patients with multiple insurance plans?

The automation routes claims to the primary payer first, then secondary and tertiary payers in the correct order. It tracks coordination of benefits and flags any coverage gaps.

Q: What reports will we receive?

You get daily reconciliation reports showing claim status, rejections, payments received, underpayments, and denials. Monthly summaries highlight trends and outstanding claims.

Cut the billing backlog by automating claim submission, status checks, and payment posting from a single workflow.

3.4k hrs

Manual time identified

Companies have mapped

Map This Automation

About This Automation

Insurance claims processing requires manual data entry across multiple payer portals, eligibility verification calls, and daily status tracking. This repetitive work consumes significant staff time and creates bottlenecks when claims are rejected.

Automation handles eligibility checks, claim submission, status monitoring, and payment reconciliation without manual intervention. Claims are submitted faster, rejections are caught and corrected automatically, and payments are matched to accounts in real time.

Key features:

Verify patient eligibility automatically by querying payer systems before claim submission

Format and submit claims to multiple payers without manual portal entry

Monitor claim status daily and flag rejections with correction recommendations

Match incoming payments to submitted claims and post them to patient accounts

Produce daily reconciliation reports to identify underpayments and denials

Route claims to the correct payer based on patient insurance coverage

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	Manual payer portal entry Each payer has a different portal layout, requiring staff to manually enter the same data repeatedly across systems.	80%
2	Claim rejection rework Rejected claims require staff to identify the error, correct it, and resubmit, often taking 7-10 days per cycle.	67%
3	Daily status monitoring Staff must check multiple payer portals and email inboxes daily to track claim progress and catch rejections early.	53%
4	Eligibility verification delays Calling payers to confirm coverage is time-consuming and creates bottlenecks when lines are busy or staff are unavailable.	40%
5	Manual payment matching Remittance advice must be manually matched to claims and posted to patient accounts, increasing reconciliation time.	26%

Disclaimer

Automation readiness

How well-suited this process is for automation

Process Pain Score™

8.5/ 10

AI Fit Rating™

9.1/ 10

Automation Lift Index™

8.7/ 10

Hidden Overhead™

7.3/ 10

How The Automation Works

The full workflow, from trigger to completion.

1. Patient Visit Documentedtrigger

A completed patient visit record is created in the practice management system with service codes and diagnosis codes.

2. Extract Claim Data

The automation extracts patient demographics, service details, and insurance information from the practice management system and formats it for submission.

3. Verify Eligibility

The automation queries the payer's eligibility API to confirm coverage is active and retrieve current deductible and copay information.

4. Route to Correct Payer

The automation identifies the correct payer based on the patient's insurance plan and routes the claim data to that payer's submission system.

5. Submit Claim

The automation submits the claim electronically to the payer using the payer's API or secure file transfer, and logs the submission timestamp.

6. Monitor Claim Status

The automation polls the payer's status API daily and flags any rejections, denials, or payment notifications immediately.

7. Alert on Rejection

If a claim is rejected, the automation sends an alert to the billing team with the rejection reason and recommended action.

8. Reconcile Payment

When payment is received, the automation matches the remittance advice to the original claim, posts the payment to the patient account, and updates the claim status.

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

1.2k hrsIdentified

24Mapped

View

Frequently asked questions

Everything you need to know before mapping this process.

What happens if a claim is rejected by the payer?

The automation identifies the rejection reason, applies the correction automatically if it is a data error, and resubmits the claim. Complex denials are escalated to your billing team for review.

Do we still need staff to review claims before they are submitted?

Will this work with all of our insurance payers?

How does the system handle patients with multiple insurance plans?

What reports will we receive?

View more FAQs

Process pain:8.5/10

Mapped by:26 Companies

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Page updated 10 August 2026