Electronic claim submission automation

Purpose

1. Automate the entire process of submitting electronic insurance claims from chiropractic clinics to private and public payers, eliminating manual entry, reducing errors, cutting submission time, increasing acceptance rates, supporting compliance standards (e.g., HIPAA), and expediting reimbursements.

2. Automator orchestrates claim data extraction from EHR systems, digitally formats the claims (X12 EDI 837), attaches supporting documents, applies payer-specific rules, and tracks claim status from initial submission to payment.

Trigger Conditions

1. New patient consultation completed and coded in EHR.

2. Provider notes finalized and CPT/ICD codes assigned.

3. Billing staff marks encounter as “Ready for claim” in PMS/EHR.

4. End-of-day batch processing scheduled for all new claims.

5. Manual override by billing supervisor for urgent claims.

6. Claims returned from clearinghouse with “fix and resend” status.

Platform Variants

1. AdvancedMD

• API: Claims API for creating and submitting new insurance claims; Configure authentication, patient, provider, codes, and attachments.
  

2. Kareo

• Function: Claims API to automate submission; Map EHR encounter data to API request body, enable webhook status updates.
  

3. Athenahealth

• Endpoint: /claims/submit; Automate X12 837 file construction and submission, set notification callback URL.
  

4. Practice Fusion

• Feature: Automated claim export to external clearinghouse; Configure trigger on billable encounter.
  

5. DrChrono

• API: /claims endpoint; Automator builds claim JSON, submits, retrieves claim status.
  

6. Office Ally

• Function: SFTP automated X12 837 file upload; Script uploads batched files on claim generation.
  

7. Availity

• API: /claims/submit for automated claim ingestion; Monitor acknowledgment files.
  

8. Navicure (Waystar)

• Endpoint: Automated EDI gateway; Scheduler posts claims via SFTP/API at set intervals.
  

9. Solutionreach

• Integration: Automated push of claim status SMS/email notifications; Setup mapped to claim status change event.
  

10. NextGen Healthcare

• API: /claims/automated-submission; Links EHR events to automated batch creation and upload.
  

11. Greenway Health

• Feature: EDI Claims Automation; Set rule to auto-export claims upon encounter completion.
  

12. Medisoft (eMDs)

• Function: Automated batch electronic claim file generation; Cron job zips and transfers to clearinghouse.
  

13. SimplePractice

• Endpoint: Automated Insurance Claim Submission; Set to trigger when invoice/payment logged.
  

14. OpenEMR

• Plugin: X12 837 file auto-generation and SFTP sync to clearinghouse.
  

15. Practice Mate

• Feature: Auto-claim export; Map patient and service fields on new cases.
  

16. Cerner

• API: Revenue Management – Electronic Claim Submission; Automatably triggered by encounter closure.
  

17. Epic

• Function: Chronicles Rules Engine – Automated EDI batch export; Linked to provider signature event.
  

18. TXEN (TriZetto)

• API: /claims; Set SFTP trigger on batch times for mass file upload.
  

19. Allscripts

• Endpoint: Claim Submission API; Use encounter-complete webhook as automation trigger.
  

20. TherapyNotes

• Function: Automatic Insurance Claim Generation; Set to trigger upon closing therapy note with billable codes.
  

Benefits

1. Automates reduction of clerical errors, ensures compliance, boosts claim acceptance and first-pass yield.

2. Automator enables real-time submission and confirmation, reduces claim lifecycle time.

3. Automated tracking and notifications streamline follow-up on denials or rejections.

4. Automation reduces labor costs and frees billing staff for value-driven tasks.

5. Automatable reporting for claims in-flight and payment status enhances revenue forecasting.

6. Automating cross-checks for coding and documentation minimizes risk of audits and payer delays.

7. Automatedly expedites cash flow by shortening reimbursement cycles for chiropractic medical services.