Insurance and rebate claims processing requires manual eligibility checks, document preparation, portal submissions, and weekly status monitoring across multiple payers. Manual tracking creates delays, missed deadlines, and overdue claim backlogs that tie up billing staff.
Automation queries payer APIs for eligibility, formats and submits claims in parallel, monitors status daily, and escalates overdue claims automatically. This reduces processing time, accelerates payment cycles, and eliminates deadline misses.
The full workflow, from trigger to completion.
A patient session is marked complete in the practice management system or a billing record is created. The automation captures session details including patient name, date, service code, duration, and provider.
The automation reads session data from the practice management system and validates all required fields. Missing or invalid data triggers a manual review step.
The automation queries payer eligibility APIs or accesses cached eligibility data to confirm coverage, copay, deductible, and prior authorization requirements without manual portal login.
The automation compiles session notes, service codes, and supporting documents, then formats the claim according to each payer's requirements and generates a PDF.
The automation submits the formatted claim to each payer's portal or email endpoint in parallel, records submission timestamps and reference numbers, and logs the action.
The automation queries payer status APIs daily and updates a central claim ledger. If a claim is unpaid after 30 days, it automatically escalates to the billing team via email.
When payment is received and matched to the claim, the automation records the transaction and updates the patient record with payment confirmation.
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