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.
The full workflow, from trigger to completion.
A completed patient visit record is created in the practice management system with service codes and diagnosis codes.
The automation extracts patient demographics, service details, and insurance information from the practice management system and formats it for submission.
The automation queries the payer's eligibility API to confirm coverage is active and retrieve current deductible and copay information.
The automation identifies the correct payer based on the patient's insurance plan and routes the claim data to that payer's submission system.
The automation submits the claim electronically to the payer using the payer's API or secure file transfer, and logs the submission timestamp.
The automation polls the payer's status API daily and flags any rejections, denials, or payment notifications immediately.
If a claim is rejected, the automation sends an alert to the billing team with the rejection reason and recommended action.
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.
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