Claims Management

Our Claims Management Process

Our claims management process is built for speed and accuracy. From initial claim creation to tracking reimbursements, we ensure every step is optimized to reduce errors and accelerate payments.

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Encounter & Charge Capture

The integrity of the claim begins with accurate charge capture. We ensure that every clinical encounter is converted into a billable service with no missing data.

✔️ Collect patient encounter data from EHR, intake forms, and provider notes

✔️ Verify:

Date of service
Rendering provider and location
Service type and visit level

✔️ Flag any missing, duplicate, or conflicting charge entries for provider review

✔️ Cross-reference documentation to ensure each procedure has supporting notes

✔️ Assign preliminary CPT codes or service categories when providers use general descriptions

✔️ Educate providers on frequent charge omissions or documentation gaps

Coding Review & Validation

Before any claim is built, we ensure that the coding is fully compliant, complete, and optimized for reimbursement tailored to specialty and payer.

✔️ Apply correct CPT, ICD-10, and HCPCS codes

✔️ Add necessary modifiers (e.g., 25, 59, LT/RT) based on documentation and policy

✔️ Validate medical necessity using payer guidelines (e.g., LCD/NCD references)

✔️ Check for:

NCCI edit violations
Bundled vs. unbundled services
E/M service rules and time-based coding

✔️ Flag potential upcoding/downcoding or mismatches between notes and codes

✔️ For surgical/procedural specialties, confirm correct global period usage

Payer-Specific Claim Configuration

Every payer has unique requirements. We tailor the claim build to match the precise rules of each payer, so you’re not caught off guard.

✔️ Confirm:

Payer ID
Taxonomy codes
Billing/rendering provider NPI
Credentialing & enrollment status

✔️ Align claims with payer-specific configurations:

POS codes (e.g., 11 vs 22)
Billing formats (CMS-1500 vs UB-04)
Telehealth modifiers and claim type flags
Identify payers that require additional attachments or documentation flags
Format according to Medicare, Medicaid, commercial, and WC/Auto specifications
Route specialty services through carve-out networks if applicable

Insurance & Eligibility Cross-Check

Before we hit submit, we re-check the insurance data to make sure it hasn’t changed, expired, or created COB issues preventing unnecessary rejections.

✔️ Reconfirm:

Primary insurance coverage
Policy effective/termination dates
Plan type (HMO, PPO, Medicare Advantage, etc.)

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✔️ Validate:

Patient demographics
Subscriber relationship
Coordination of Benefits (COB) status

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✔️ Detect:

Termed policies
Invalid group numbers
Incorrect insurance sequencing

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✔️ For accident/injury claims, confirm liability vs health coverage order.

Claim Scrubbing & Pre-Submission Audit

We use both technology and expertise to catch issues before they happen. Clean claims reduce AR days and eliminate back-end denials.

✔️ Pass each claim through automated scrubbing engines for:

Format issues
Missing fields
Code compatibility errors

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✔️ Manually audit:

High-risk procedures
Claims with prior denials
Flags like missing NPIs or mismatched diagnosis

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✔️ Review logic-based edits:

Age/gender conflicts
Invalid revenue codes or DRG mismatches

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✔️ Prevent duplicate claim submissions

✔️ Track scrubbed errors and resolve them in real-time before submission

Electronic Claim Submission

The final step in claims management is submission, but we don’t just send and forget. We track every single claim through to acceptance.

✔️ Batch claims by payer or claim type and transmit electronically via:

Clearinghouse
Direct-to-payer integration

✔️ Confirm:

Successful transmission
Payer acknowledgment reports (277, 999)

✔️ Log:

Claim tracking IDs
Batch confirmation
Expected payer response timeline

✔️ Queue claim for follow-up or rejection review based on clearinghouse feedback

✔️ Monitor for scrub-to-acceptance ratio and optimize for 98%+ clean claim rate

The final step in claims management is submission, but we don’t just send and forget. We track every single claim through to acceptance.

✔️ Batch claims by payer or claim type and transmit electronically via: