Insurance authorisations and claims processing at specialist medical clinics involves manual verification of patient eligibility, compilation of authorisation requests, and tracking of approvals across multiple payer systems.
Automation handles eligibility verification, authorisation request submission, claim assembly, and payment reconciliation in real time. The result is faster approvals, fewer errors, and staff freed from repetitive data entry to focus on exceptions and denials.
The full workflow, from trigger to completion.
Patient appointment is scheduled and insurance information is captured in the practice management system or booking form. The automation is triggered when a new booking record is created.
The automation extracts patient demographics, insurance member ID, group number, and plan details from the booking record and validates the data format. Invalid or missing fields are flagged for manual review.
The automation submits an eligibility query to the payer via API or secure portal, retrieving real-time coverage status, deductible, copay, and authorisation requirements. Results are stored in the billing system.
If authorisation is required, the automation compiles the clinical justification, procedure codes, and patient data into the payer's required format and submits the request electronically. A submission confirmation and reference number are logged.
The automation polls the payer portal or email inbox daily for authorisation responses. When approval is received, authorisation details are extracted and a notification is sent to the billing team.
After treatment is completed, the automation retrieves service codes, charges, and authorisation details from the billing system and submits the claim to the payer in the required format. Submission confirmation is logged.
The automation monitors claim status and remittance advice. When payment is received, the automation matches the remittance to the claim, records the payment, and updates the patient account status.
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