Automated processing of claim denials

Purpose

1. Streamline review, categorization, and reprocessing of insurance claim denials for alcoholism treatment programs.

2. Automatically extract denial details from payor responses, validate patient and claim info, and generate appeal or correction documents.

3. Route denials to appropriate staff, trigger notifications, and update claim status in EHR and billing systems.

4. Reduce manual workload, shorten reimbursement cycles, minimize revenue leakage, and ensure compliance with regulatory reporting for addiction recovery centers.

Trigger Conditions

1. Receipt of electronic remit advice (ERA/835 files) indicating denial status.

2. Notification from clearinghouse APIs on claim status changes.

3. Upload or email receipt of paper denial letters.

4. Direct status query via payor web portal API showing denial.

5. Manual entry of denied claims by billing staff.

Platform Variants

1. Epic Systems EHR

• API: Denial Management APIs — configure webhook for real-time denial event push to automation.
  

2. Cerner

• API: RevElate Claims Response — enable event triggers on denial code entries.
  

3. AdvancedMD

• Feature: Claim Denial Alerts — set up auto-forward to processing workflows via webhook.
  

4. Athenahealth

• API: Claims v1 List — poll for claims with "denied" status; auto-enrich with patient data.
  

5. NextGen Healthcare

• API: Claim Management Endpoints — configure auto-export of denial batches to automation endpoint.
  

6. Availity

• API: Remit Data Service — trigger on remit/835 file with denial code (e.g., PR-49); auto-forward to workflow.
  

7. Change Healthcare

• API: Intelligent Healthcare Network — subscribe for denial event topics; map codes for automated enrichment.
  

8. Office Ally

• API: Claim Status — programmatically retrieve new denials and trigger data extraction routine.
  

9. Kareo

• Feature: Denial Tasking API — auto-create follow-up tasks and assign based on denial reason.
  

10. Greenway Health Intergy

• API: Workflow Notifier — export every claim with EOB showing denial to processing automation.
  

11. HealthEdge

• API: SmartClaims Denial Event — event configuration to update downstream workflows on denial.
  

12. eClinicalWorks

• API: Denial Extraction — set webhook for new denial notifications to external automation.
  

13. Surescripts

• API: Clinical Messaging — utilize notification if claim is denied for medication-related services.
  

14. Experian Health

• Feature: Eligibility/ClaimStatus API — set real-time denial triggers; pass data to appeal routines.
  

15. Emdeon (Change Healthcare legacy)

• API: Real-Time Claim Status — enable denial alerts via automation endpoint.
  

16. Salesforce Health Cloud

• API: Case Management — auto-open denial case on denial input; integrate follow-up sequencing.
  

17. Zendesk

• API: Ticketing — generate denial tickets for each claim and assign workflows by category.
  

18. DocuSign

• API: Envelope Creation — automatically generate signature packets for corrected/appeal documents.
  

19. Google Cloud Document AI

• API: OCR/Parsing — ingest scanned/paper denial letters and extract reason codes for workflow branching.
  

20. AWS Textract

• API: AnalyzeDocument — auto-ingest PDF/scan denials to initiate automation flows.
  

21. Microsoft Power Automate

• Flow Connector: Schedule periodic run to check for new denials and initiate downstream processes.
  

22. Slack

• API: Incoming Webhook — deliver instant alert to billing/revenue team for specific denial groups.
  

23. PagerDuty

• API: Event Trigger — escalate critical denials via incident workflows to management.
  

24. SAP Concur

• API: Reimbursement Workflows — auto-sync claim denial data for expense reconciliation triggers.
  

25. QuickBooks Online

• API: Invoices/Credits — adjust revenue ledgers automatically based on denial outcomes.
  

Benefits

1. Expedites claim reprocessing and appeals, improving revenue collection speed.

2. Reduces error rates due to automated extraction and validation.

3. Cuts manual workload, enabling staff to focus on complex denials or patient care.

4. Enhances tracking, accountability, and regulatory compliance for addiction recovery providers.

5. Provides real-time insights on denial patterns to inform payer negotiations and operational improvements.