Expert Claims Processing
Maximize your reimbursements with our advanced claims processing service. We achieve 98.7% clean claim rates and submit claims within 24 hours using AI-powered validation and specialty expertise.
Industry-Leading Claims Performance
Our advanced claims processing consistently outperforms industry benchmarks
Our Advanced Claims Processing Workflow
Six-step process designed for maximum accuracy, speed, and reimbursement optimization
Claim Creation & Assembly
Comprehensive claim creation from complete patient demographic and clinical data with automatic coding validation.
Patient information verification, service coding, documentation review, and claim formatting according to payer specifications.
Pre-Submission Scrubbing
Advanced automated and manual claim validation against 3,000+ built-in edits and payer-specific requirements.
Error detection, modifier validation, bundling checks, medical necessity verification, and compliance screening.
Electronic Submission
Direct electronic transmission to payers using secure EDI protocols with real-time acknowledgment tracking.
Batch processing, individual claim routing, submission status monitoring, and acknowledgment reconciliation.
Real-Time Tracking
Continuous claim status monitoring from submission through adjudication with automated status updates.
Payer acknowledgment tracking, adjudication monitoring, payment posting alerts, and denial notifications.
Payment Processing
Automated ERA processing, payment posting, and reconciliation with detailed variance analysis.
Electronic remittance processing, payment allocation, adjustment posting, and account reconciliation.
Denial Management
Systematic denial analysis, root cause identification, and rapid resubmission with corrective actions.
Denial categorization, appeal preparation, corrective resubmission, and prevention strategy implementation.
Comprehensive Claim Type Coverage
Expert processing for all claim types with specialized knowledge and validation
Professional Claims (CMS-1500)
Physician and non-institutional provider claims for outpatient services, office visits, and procedures.
Services Included:
- Office visits and consultations
- Outpatient procedures and surgeries
- Diagnostic testing and lab services
- Therapy and rehabilitation services
- Preventive care and wellness visits
- Telehealth and remote monitoring
Common Challenges:
- ⚠Complex modifier requirements
- ⚠Place of service accuracy
- ⚠Preventive care coding
- ⚠Multiple procedure billing
Our Expertise:
- ✓Specialty-specific coding knowledge
- ✓Modifier optimization strategies
- ✓Payer policy compliance
- ✓Documentation requirements
Institutional Claims (UB-04)
Hospital and facility claims for inpatient, outpatient, and emergency department services.
Services Included:
- Inpatient hospital stays
- Outpatient hospital services
- Emergency department visits
- Ambulatory surgery centers
- Skilled nursing facilities
- Home health services
Common Challenges:
- ⚠DRG assignment accuracy
- ⚠Revenue code selection
- ⚠Condition code requirements
- ⚠Occurrence code timing
Our Expertise:
- ✓Hospital billing specialists
- ✓DRG optimization
- ✓Revenue cycle integration
- ✓Compliance monitoring
Dental Claims (ADA Forms)
Dental procedure claims including preventive care, restorative services, and oral surgery.
Services Included:
- Preventive dental services
- Restorative procedures
- Oral surgery and extractions
- Orthodontic treatment
- Periodontal therapy
- Prosthodontic services
Common Challenges:
- ⚠Insurance benefit limitations
- ⚠Treatment plan approval
- ⚠Cosmetic vs. necessary care
- ⚠Frequency limitations
Our Expertise:
- ✓Dental coding specialists
- ✓Insurance navigation
- ✓Treatment authorization
- ✓Benefit optimization
Advanced Claims Scrubbing & Validation
Over 3,000 validation checks prevent denials before submission
Patient Demographics
- Name and DOB accuracy
- Insurance ID verification
- Gender consistency
- Address validation
- Subscriber relationship
- Eligibility confirmation
Clinical Coding
- ICD-10 diagnosis validity
- CPT procedure accuracy
- Modifier appropriateness
- Code sequence logic
- Medical necessity support
- Bundling compliance
Billing Compliance
- Timely filing requirements
- Prior authorization status
- Coordination of benefits
- Duplicate claim detection
- Global period awareness
- Incident-to guidelines
Documentation
- Provider signature requirements
- Date of service accuracy
- Place of service validation
- Referring provider information
- Medical record availability
- Supporting documentation
Cutting-Edge Claims Technology
AI-powered automation and advanced analytics optimize every aspect of claims processing
AI-Powered Claim Validation
Machine learning algorithms analyze claims against historical denial patterns and payer-specific requirements.
Key Features:
- Predictive denial prevention
- Automated error detection
- Pattern recognition analysis
- Continuous learning optimization
Real-Time Eligibility Verification
Instant insurance verification and benefit checking at the point of service and claim submission.
Key Features:
- 270/271 transaction processing
- Benefit amount verification
- Coverage status confirmation
- Copay and deductible validation
Automated Claims Routing
Intelligent claim routing to appropriate payers with format optimization for each destination.
Key Features:
- Payer-specific formatting
- Automated batch creation
- Priority claim handling
- Error queue management
Advanced Analytics Dashboard
Comprehensive reporting and analytics platform providing real-time insights into claims performance.
Key Features:
- Real-time claim tracking
- Denial trend analysis
- Payer performance metrics
- Custom report generation
Specialty-Specific Claims Expertise
Dedicated specialists for complex medical specialties ensure optimal reimbursement
Cardiology
Challenges:
- •Complex procedure bundling
- •Cardiovascular modifier usage
- •Multiple vessel procedures
- •Professional vs. technical components
Our Solutions:
- ✓Cardiologist-trained coders
- ✓Procedure-specific edits
- ✓Real-time coding support
- ✓Documentation optimization
Orthopedic Surgery
Challenges:
- •Surgical complexity coding
- •Hardware and implant billing
- •Global surgical packages
- •Multiple procedure discounting
Our Solutions:
- ✓Orthopedic coding specialists
- ✓Surgical workflow integration
- ✓Implant tracking systems
- ✓Global period management
Emergency Medicine
Challenges:
- •High-volume rapid processing
- •Critical care documentation
- •Facility vs. professional billing
- •After-hours service coding
Our Solutions:
- ✓24/7 processing capability
- ✓Emergency coding experts
- ✓Rapid-turnaround systems
- ✓Critical care optimization
Mental Health
Challenges:
- •Session-based billing complexity
- •Outcome measurement requirements
- •Authorization management
- •Telehealth compliance
Our Solutions:
- ✓Behavioral health specialists
- ✓Session optimization tools
- ✓Authorization tracking
- ✓Telehealth billing expertise
Real-World Success Stories
See how our claims processing expertise transformed these healthcare practices
Multi-Specialty Clinic Transformation
Challenge
Large clinic with 15 providers experiencing 12% denial rate and 6-day claim submission delays.
Solution
Implemented automated claim scrubbing, real-time eligibility verification, and specialty-specific coding review.
Results
- ✓Denial rate reduced from 12% to 1.8%
- ✓Submission time decreased from 6 days to 18 hours
- ✓Monthly collections increased by 28%
- ✓Staff overtime reduced by 40%
Orthopedic Surgery Center Optimization
Challenge
Surgery center struggling with complex procedure coding and implant billing, resulting in frequent denials.
Solution
Deployed orthopedic coding specialists and implemented surgery-specific claim validation workflows.
Results
- ✓Clean claim rate improved from 82% to 98.1%
- ✓Implant claim denials eliminated
- ✓Average reimbursement per case increased by 15%
- ✓Coding staff training time reduced by 60%
Emergency Department Revenue Recovery
Challenge
Hospital ED losing revenue due to incomplete documentation and delayed claim submission.
Solution
Implemented real-time claim processing with emergency medicine coding expertise and documentation improvement.
Results
- ✓Submission delays eliminated (same-day processing)
- ✓Documentation compliance increased to 99.2%
- ✓Monthly revenue increased by $180,000
- ✓Denial rate reduced from 9.8% to 2.1%
Frequently Asked Questions
Get answers to common questions about our claims processing services
How quickly are claims submitted after services are rendered?
Our automated system processes and submits claims within 24 hours of service completion. For urgent claims or high-priority accounts, we can achieve same-day submission. This rapid turnaround significantly improves cash flow compared to industry averages of 3-5 days.
What types of edits and validations do you perform before submission?
We perform over 3,000 different validation checks including demographic verification, coding accuracy, medical necessity review, modifier validation, bundling compliance, and payer-specific requirements. Our AI-powered system continuously learns from denial patterns to prevent future errors.
How do you handle claims that are denied or rejected?
Denied claims are immediately analyzed by our specialists to identify root causes. We categorize denials, implement corrective actions, and resubmit within 48 hours. Our systematic approach achieves a 96.2% success rate on resubmitted claims, compared to the industry average of 78%.
Can you process claims for multiple specialties and payers?
Yes, we process claims for over 40 medical specialties and work with 1,200+ payers nationwide. Our team includes specialty-specific coding experts who understand the nuances of each medical field and payer requirements, ensuring optimal reimbursement for every specialty.
What reporting and analytics do you provide for claims processing?
Our advanced dashboard provides real-time claim tracking, denial trend analysis, payer performance metrics, and custom reporting. You can monitor claim status, identify bottlenecks, track key performance indicators, and access detailed analytics to optimize your revenue cycle.
How do you ensure compliance with changing regulations and payer requirements?
We maintain a dedicated compliance team that monitors regulatory changes, payer policy updates, and industry requirements. Our system is automatically updated with new edits and requirements, and our staff receives continuous training to ensure ongoing compliance.
What happens if a claim requires additional documentation or information?
We have established workflows for handling information requests. Our team immediately identifies what's needed, contacts your practice for the required documentation, and resubmits the claim promptly. We track these requests to prevent future occurrences and improve documentation processes.
How do you handle high-volume claim processing during peak periods?
Our scalable technology platform and experienced team can handle volume surges without delays. We use automated batch processing, intelligent queuing systems, and have backup capacity to ensure consistent processing times even during peak periods like end-of-month or after holidays.
Ready to Optimize Your Claims Processing?
Join hundreds of healthcare providers who have improved their clean claim rates to 98.7% and reduced denial rates to just 1.6% with our expert claims processing services.
✓ No setup fees ✓ 30-day implementation ✓ Guaranteed improvement