Claims Management
Streamline your claims processing with our advanced automation system that ensures accuracy and faster reimbursement.
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Claims Management
Our Claims Management service is designed to help practices maximize revenue and reduce time spent on billing tasks. With built-in automation and expert oversight, we reduce submission time by up to 75% and maintain a 98%+ clean claim rate, minimizing rejections, and accelerating payment.
No more manual errors. No more backlogs. Just clean, compliant claims submitted right the first time.
Key Benefits
Faster Submissions
Reduce turnaround time by 75% with automated claim workflows.
Cleaner Claims
98%+ clean claim rate through smart error detection + expert review.
Faster Reimbursements
Eliminate delays and get paid quicker without chasing payers.
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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Claim Preparation
Collect and verify all required patient and coding data.
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Automated Submission
Submit clean claims electronically to payers with built-in validation.
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Tracking & Monitoring
Continuously monitor claim status for delays or rejections.
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Reimbursement Posting
Post payments and reconcile with financial systems for full transparency.
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.
Encounter & Charge Capture
Collect patient encounter data from the EHR, intake forms, or provider notes
Verify date of service, rendering provider, location, and service type
Flag missing or inconsistent charge entries for correction
Foundation of a claim starts with accurate charge capture.
Coding Review & Validation
Apply correct CPT, ICD-10, and HCPCS codes
Add appropriate modifiers based on payer policy and procedure documentation
Validate medical necessity based on documentation
Check for NCCI edits, bundling, and unbundling risks
Proper coding = maximum allowable reimbursement.
Payer-Specific Claim Configuration
Confirm payer ID, billing taxonomy, provider credentialing status
Populate required claim fields based on each payer’s format
Ensure claim aligns with payer-specific billing rules (e.g., POS codes, claim type)
Every payer has quirks. We prepare for them upfront.
Insurance & Eligibility Cross-Check
Reconfirm insurance coverage and policy effective dates before submission
Validate patient demographics, plan details, and coverage type
Identify and flag COB (coordination of benefits) issues when applicable
Coverage errors are one of the top causes of rejected claims.
Claim Scrubbing & Pre-Submission Audit
Run every claim through automated scrubbers for format, code, and logic errors
Manually review claims flagged by scrubbers or with high denial risk
Check for duplicates, date inconsistencies, missing NPIs, or invalid combinations
Our goal: a 98%+ clean claim rate. No rework required.
Electronic Claim Submission
Batch claims and submit via clearinghouse or direct-to-payer connection
Confirm transmission success with acknowledgment reports
Log payer tracking IDs for downstream adjudication follow-up
Every clean claim is tracked from send to status.
+ 📋 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.)
✔️ Validate:
- Patient demographics
- Subscriber relationship
- Coordination of Benefits (COB) status
✔️ Detect:
- Termed policies
- Invalid group numbers
- Incorrect insurance sequencing
✔️ 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
Manually audit:
- High-risk procedures
- Claims with prior denials
- Flags like missing NPIs or mismatched diagnosis
Review logic-based edits:
- Age/gender conflicts
- Invalid revenue codes or DRG mismatches
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
