| 01Insurance Eligibility & Benefits Verification |
Checks whether a patient has active coverage and retrieves available benefit, deductible, copay, and payer information before services are billed. |
Enter Patient & Insurance Details→
Send Eligibility Request→
Receive Coverage Response→
Update Billing Record
|
Real-time eligibility checks with required payers
Coverage, deductible, copay, coinsurance, and benefit details
Batch eligibility verification for upcoming appointments
|
| 02Charge Capture & Medical Coding |
Converts documented services into billable charges using diagnosis, procedure, modifier, provider, and place-of-service information. |
Capture Services Performed→
Assign Codes & Modifiers→
Validate Charge Details→
Create Billable Claim
|
ICD, CPT, HCPCS, modifier, and specialty-specific coding support
Charge capture from EHR or encounter documentation
Coding edits and configurable fee schedules
|
| 03Claim Scrubbing & Validation |
Checks claims for missing information, coding conflicts, formatting errors, payer requirements, and other issues that could lead to rejection or denial. |
Create Claim→
Run Billing & Coding Edits→
Flag Errors / Missing Data→
Correct before Submission
|
Payer-specific and specialty-specific validation rules
Coding, demographic, authorization, and format checks
Clear error explanations and correction workflows
|
| 04Electronic Claims Submission & Tracking |
Transmits claims electronically to clearinghouses or payers and monitors acknowledgments, rejections, acceptance, and adjudication status. |
Approve Clean Claim→
Submit Electronically→
Receive Payer / Clearinghouse Status→
Track until Adjudication
|
Electronic claim support for required payer types
Clearinghouse connectivity and claim-status visibility
Rejection queues, resubmission, and timely-filing tracking
|
| 05Electronic Remittance & Payment Posting |
Processes payer remittance data and posts payments, contractual adjustments, patient responsibility, denials, and other adjudication outcomes to accounts. |
Receive ERA / Remittance→
Match to Claims→
Post Payments & Adjustments→
Update Outstanding Balances
|
ERA and electronic payment reconciliation
Automatic posting of payments, adjustments, and patient responsibility
Exception handling for unmatched or underpaid claims
|
| 06Denial & Rejection Management |
Organizes rejected and denied claims, identifies reasons, assigns follow-up work, tracks appeals, and supports corrected claim resubmission. |
Receive Rejection / Denial→
Identify Reason & Priority→
Correct / Appeal Claim→
Resubmit & Track Outcome
|
Denial categorization by reason, payer, provider, and service
Appeal deadlines, work queues, notes, and supporting documents
Root-cause reporting for recurring denial patterns
|
| 07Patient Billing & Payment Collection |
Creates patient statements and collects copays, deductibles, coinsurance, self-pay balances, payment plans, and other patient-responsibility amounts. |
Determine Patient Responsibility→
Generate Statement / Balance→
Collect Payment→
Update Patient Account
|
Paper, email, text, and online statement options
Card, ACH, payment-plan, and stored-payment support
Copay, deposit, refund, credit, and partial-payment handling
|
| 08Accounts Receivable & Follow-Up Work Queues |
Tracks unpaid claims and patient balances by aging, payer, provider, location, or other criteria and prioritizes follow-up activity for billing staff. |
Monitor Outstanding Balances→
Segment by Aging / Payer / Issue→
Assign Follow-Up Work→
Resolve or Escalate Balance
|
A/R aging by payer, patient, provider, and service date
Custom work queues, priorities, ownership, and follow-up notes
Timely-filing, no-response, underpayment, and unresolved-balance alerts
|
| 09Billing Rules, Authorizations & Compliance Controls |
Applies payer, authorization, documentation, billing, and user-access controls to reduce preventable errors and support compliant revenue-cycle processes. |
Define Billing / Authorization Rules→
Validate Encounter Requirements→
Flag Exceptions→
Approve for Billing
|
Prior authorization and referral tracking where required
Payer-specific billing rules and documentation requirements
Role-based permissions, audit trails, and secure data access
|
| 10Revenue Cycle Reporting & Integrations |
Measures collections, denials, claim performance, reimbursement, A/R, and payment trends while connecting billing workflows with clinical and financial systems. |
Aggregate Billing Data→
Analyze Revenue Cycle KPIs→
Connect Healthcare Systems→
Improve Billing Performance
|
Clean claim rate, denial rate, days in A/R, collections, and reimbursement reporting
EHR, practice management, clearinghouse, payment, and accounting integrations
APIs, exports, custom dashboards, and multi-location reporting
|
CA
PR
DR
NE
EC
TE
CU
RX
TH
CO
PR
CH
