The claims can be entered manually or uploaded in the system. The system can also be configured to accept claims in internationally accepted EDI formats such as ANSI X12 837. As a first step, these claims are scrubbed using business rules defined in the system. The business rules will assist the system in identifying claims which must remain pending until review. Whenever possible the claims will be automatically approved or denied.
Some rules that could be configured into the business rules scrubber
Whether the service is authorized or not
Validation of patient attributes such as Patient Name, DOB, address
The system presents the claims on a GUI interface. The FEE staff will utilize these documents to review claims and if necessary escalate for further review and approval or denial. An EOB (Explanation of Benefits) will be provided by consumer on both approved and denied claims. There can be 3 to 4 level of reviews which can be configured in the workflow.
Some rules that could be configured into the business rules scrubber
Whether the service is authorized or not Validation of patient attributes such as Patient Name, DOB, address
The system presents the claims on a GUI interface. The FEE staff will utilize these documents to review claims and if necessary escalate for further review and approval or denial. An EOB (Explanation of Benefits) will be provided by consumer on both approved and denied claims. There can be 3 to 4 level of reviews which can be configured in the workflow.