Billing & Insurance ProcessingPurpose
1.2. Accelerate administrative workflows by replacing manual phone/fax/email verifications with direct system-to-payer data exchange.
1.3. Enable real-time validation of patient coverage, co-pay, deductibles, and pre-authorizations against scheduled therapy services.
1.4. Minimize human error, reduce appointment disruptions, and assure compliance with payer policies.
Trigger Conditions
2.2. Existing patient schedules new session or recurring therapy appointment.
2.3. Insurance information update submitted via portal or intake form.
2.4. Scheduled session is within 24–48 hours and no recent verification on file.
2.5. System receives notification of insurance policy expiration or potential lapses.
Platform Variants
3.1. Availity
• API: Eligibility & Benefits API
• Configure authentication and send member/policy details for instant eligibility responses.
3.2. Change Healthcare
• API: Eligibility Verification (270/271)
• Map HL7/X12 270 for patient, provider, payer codes; receive 271 electronic response.
3.3. Office Ally
• Feature: Real-Time Eligibility API
• Connect patient demographics and insurance to retrieve coverage details programmatically.
3.4. CAQH/EnrollHub
• Feature: Automated enrollment APIs
• Set up provider credentials for batch or real-time verification via EDI.
3.5. Experian Healthcare
• API: Eligibility Verification
• Integrate EDI X12 clearinghouse for real-time patient plan validation.
3.6. Sikka Software
• Function: Dental/Medical Insurance Lookup
• Use Sikka cloud APIs to query insurance in the EHR stack.
3.7. Navicure (Waystar)
• API: Eligibility & Benefits Verification
• Schedule nightly batch checks or event-based verifications.
3.8. Zirmed
• Feature: Eligibility Inquiry (via REST API)
• Initiate patient eligibility request with payer routing and extract co-payments.
3.9. Greenway Health Intergy
• API: Real-Time Eligibility
• Configure scheduled triggers for event-driven patient eligibility.
3.10. Kareo
• Feature: Integrated Real-Time Eligibility API
• Plug into intake workflows for instant insurance confirmations.
3.11. SimplePractice
• API: Insurance Eligibility Verification
• Set webhook for appointment scheduling event; query covered services.
3.12. AdvancedMD
• Feature: Insurance Verification Engine
• Use API endpoint to automate checks for ABA procedure codes.
3.13. TherapyNotes
• API: Real-Time Insurance Lookup
• Fetch payer responses on insurance status before session confirmation.
3.14. OpenEMR
• API: X12 270 Eligibility Check
• Connect EHR’s clearinghouse interface to automate benefit queries.
3.15. DrChrono
• API: Eligibility Verification
• Sample payload includes MRN, DOB, policy number, and session date.
3.16. Cerner
• FHIR API: Coverage Eligibility
• Configure FHIR-based auth to trigger eligibility check per patient event.
3.17. Epic
• API: Eligibility API (Epic App Orchard)
• Use patient context to automate insurance verification pre-appointment.
3.18. Athenahealth
• Feature: Eligibility Verification Webhook
• Listen to scheduling events; query patient insurance for ABA coverage.
3.19. NextGen
• API: Real-Time Eligibility Verification
• Trigger process on booking or intake form completion.
3.20. Salesforce Health Cloud
• API: Custom Insurance Verification Workflow
• Invoke eligibility microservice from patient record automations.
3.21. Blue Button 2.0
• API: Insurance Data Access API
• Query FHIR resource from Medicare APIs to check active coverage.
Benefits
4.2. Frees staff from repetitive insurance follow-up tasks, saving time and costs.
4.3. Ensures patient appointments are never billed outside plan coverage.
4.4. Boosts patient satisfaction by preemptively addressing insurance issues.
4.5. Maintains compliance and accurate audit trails for insurance interactions.