Insurance, Claims & Rebates

A patient transaction is completed in the practice management system and claim data is automatically extracted, including patient demographics, procedure codes, and insurance information.

The automation platform checks insurance eligibility in real time via insurer APIs, maps procedure codes to the correct payer format, and applies fee schedule adjustments automatically.

The formatted claim is submitted electronically to the insurer via their API or secure portal, and a submission confirmation is logged automatically.

The automation platform queries insurer APIs daily to check claim status and automatically flags claims that are denied, pending, or paid.

The automation evaluates each claim against rebate rules stored in a database and automatically identifies claims that qualify for rebates based on product type and volume thresholds.

Eligible rebate claims are automatically compiled with required documentation and submitted to the insurer via email or portal.

When rebate or claim payments are received, the automation matches them to original claims and rebate submissions, and records the transactions in the accounting system.

The automation sends alerts to the finance team for claims that remain unpaid beyond a threshold, denials requiring manual review, or rebate deadlines approaching.