Electronic claim submission workflows

Purpose

1.1. Automate electronic claim submissions for Pedorthist clinics in healthcare, focusing on the seamless transfer of billing and insurance data to insurers and clearinghouses.
1.2. Automating the filing process reduces manual entry, increases claim approval rates, and speeds up revenue cycles.
1.3. Enables clinics to process large claim volumes, automates error-detection, and ensures compliance with healthcare billing standards (e.g., HIPAA, ICD/HCPCS coding).
1.4. Integrates EHR/EMR systems, billing software, and insurer APIs, supporting real-time claim status updates and reducing denials.
1.5. Enables electronic claim attachments, automates patient eligibility checks, and automates payer rule validation.

Trigger Conditions

2.1. Completion of a patient appointment or intake.
2.2. Submission of a finalized billing entry in the EHR/EMR.
2.3. New insurance policy or eligibility update received.
2.4. Completion of medical documentation uploads or code assignments.
2.5. Manual or automated approval from clinic billing personnel.

Platform Variants

3.1. Change Healthcare
• Feature/Setting: Medical Network APIs – configure Claim Submission endpoint with EHR’s claim data JSON.
3.2. Availity
• Feature/Setting: Provider Portal API – automate EDI 837 batch file uploads for claim submission.
3.3. Office Ally
• Feature/Setting: Submitter Web Service – automate XML or EDI uploads to claims endpoint.
3.4. Emdeon
• Feature/Setting: WebConnect API – automate claim batch transmission via SOAP.
3.5. Kareo
• Feature/Setting: Billing API – automate POST to /claims for electronic transmission post-encounter.
3.6. AdvancedMD
• Feature/Setting: Claims Submission module – automate EDI file generation and transmission triggers.
3.7. Practice Fusion
• Feature/Setting: Integrated Claims API – automate claim file workflow and real-time eligibility triggers.
3.8. Athenahealth
• Feature/Setting: Claims API – configure automated POST requests on chart completion.
3.9. Cerner
• Feature/Setting: Millennium Claims – automate claims file creation and auto-submit through FHIR API interface.
3.10. Epic
• Feature/Setting: Resolute Billing Claims module – automate claims queue and electronic submission toggle.
3.11. NextGen Healthcare
• Feature/Setting: EDI-X12 Claims Service – automate claims batch submission through SFTP or direct API.
3.12. DrChrono
• Feature/Setting: Insurance API – automate claim creation and submit via REST endpoint.
3.13. Greenway Health
• Feature/Setting: Prime Suite API – automate claim transmission workflow on completion event.
3.14. Xactimed
• Feature/Setting: Claims API – automate batch electronic claim uploads and acknowledgements.
3.15. Medisoft
• Feature/Setting: Revenue Management module – automate EDI 837 generation and FTP submission.
3.16. PracticeSuite
• Feature/Setting: Claims Module – automate claim upload and status update via integrated API.
3.17. SimplePractice
• Feature/Setting: Claims automation setting – toggle auto-generation and direct submission.
3.18. TriZetto Provider Solutions
• Feature/Setting: EDI Connection Service – automate X12 837P upload and error checking.
3.19. OpenEMR
• Feature/Setting: Billing module – automate X12 EDI claims file export and scheduled auto-uploads.
3.20. Waystar
• Feature/Setting: Submission API – automate claim file transfer initiation and status webhook.

Benefits

4.1. Automates repetitive claim entry tasks, reducing administrative overhead.
4.2. Minimizes human error, increasing clean claim rate and automating error alerts.
4.3. Accelerates payment cycles and automates eligibility rechecks and claim statuses.
4.4. Enables scalable automation of high-volume submissions, supporting rapid clinic growth.
4.5. Improves compliance by automating payer-specific rules and automated documentation checks.
4.6. Frees staff for higher-value patient care tasks by automating claim workflows end-to-end.