Authorisations & Claims

Q: Can the automation handle different payer requirements and submission formats?

Yes. The automation adapts to each payer's portal, EDI format, and data requirements.

Q: What happens to existing authorisation and claims data when automation starts?

Historical data is migrated into the billing system and communication tools so the automation can track and reconcile all open and pending items without data loss.

Q: How does the automation handle claims that are partially paid or have contractual adjustments?

Remittance advice is parsed automatically to identify partial payments, denials, and adjustments. Discrepancies are flagged for the billing team to investigate and reconcile manually.

Q: Can staff still manually override or adjust authorisation and claim submissions?

Yes. The automation provides a dashboard where staff can review, edit, and resubmit requests before they go to the payer, or override automated decisions for exceptions.

Keep authorisation requests moving and claims paid by removing the manual follow-up and rekeying that stall your billing cycle.

308 hrs

Manual time identified

Companies have mapped

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About This Automation

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.

Key features:

Query payer systems automatically for real-time eligibility and coverage limits

Compile and submit authorisation requests electronically without manual re-entry

Monitor authorisation status and escalate denials for billing team review

Assemble claim data from the billing system and submit in the correct payer format

Reconcile payments against remittance advice and flag rejections for investigation

Track all submissions and responses in a single audit trail

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 logins Staff spend time logging into multiple payer portals daily to check eligibility and claim status.	80%
2	Data re-entry across systems Authorisation and claim details are transcribed manually from payer portals into the billing system.	67%
3	Slow authorisation turnaround Manual follow-up calls and email checks delay approval responses by 5-7 business days.	53%
4	Inconsistent status tracking Authorisation and claim status updates are scattered across email, spreadsheets, and portal notes.	40%
5	Manual payment matching Remittance advice is matched to claims manually, creating reconciliation delays and discrepancies.	26%

Disclaimer

Automation readiness

How well-suited this process is for automation

Process Pain Score™

8.4/ 10

AI Fit Rating™

8.6/ 10

Automation Lift Index™

8.4/ 10

Hidden Overhead™

7.3/ 10

How The Automation Works

The full workflow, from trigger to completion.

1. Patient Booking with Insurance Detailstrigger

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.

2. Extract and Validate Patient Data

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.

3. Query Insurance Eligibility and Coverage

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.

4. Generate and Submit Authorisation Request

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.

5. Monitor Authorisation Status and Notify Team

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.

6. Prepare and Submit Claim

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.

7. Track Claim and Log Payment

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.

Most popular tool stack used

— the complete tool combinations companies use

52% of companies

28% of companies

19% 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

528 hrsIdentified

4Mapped

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Frequently asked questions

Everything you need to know before mapping this process.

What happens to authorisation requests that are denied or require additional information?

Denials and coverage gaps are automatically flagged and escalated to the billing team with the payer's reason code and required documentation. Staff review and resubmit with updated clinical justification or appeal.

Can the automation handle different payer requirements and submission formats?

What happens to existing authorisation and claims data when automation starts?

How does the automation handle claims that are partially paid or have contractual adjustments?

Can staff still manually override or adjust authorisation and claim submissions?

View more FAQs

Process pain:8.4/10

Mapped by:4 Companies

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Page updated 10 August 2026