Claims submission automation

Purpose

1. Streamline the submission of insurance claims for ABA therapy providers by automating intake, validation, formatting, and electronic submission.

2. Reduce billing errors, accelerate reimbursements, and ensure compliance with insurance and healthcare data regulations.

3. Enable real-time updates, rejection alerts, and integrated patient/claim data handling between EHR, RCM, and payer systems.

Trigger Conditions

1. New patient session marked as complete in an EHR or practice management system.

2. Provider uploads or approves service documentation for billing.

3. Received timeframe triggers (e.g., end-of-day batch, weekly cycle).

4. Manual confirmation by billing admin or therapist.

Platform Variants

1. Kareo API

• Function: /claims endpoint for claim creation/submission; configure with patient, provider, and session data payload.
  

2. SimplePractice Webhooks & API

• Feature: Appointment completion webhook; API call to /insurance_claims for automated claim entry.
  

3. TheraNest API

• Function: POST /insurance/claims; input session details, ICD-10, CPT codes.
  

4. Office Ally SFTP Submission

• Setting: Automated SFTP upload for CMS-1500/837P EDI files formatted per payer specs.
  

5. Availity EDI Gateway

• Feature: API endpoint for 837 submission; map patient/session fields to standard EDI segments.
  

6. TherapyNotes API

• Function: /Claims POST endpoint; configure client ID, service codes, diagnosis, provider NPI.
  

7. AdvancedMD API

• Feature: CreateClaim API method; payload includes encounter, provider, and payer details.
  

8. CentralReach API

• Function: /claims/submit; auto-fill fields from finalized session notes and authorizations.
  

9. Greenway Health Intergy API

• Feature: Claims/submit endpoint; batch process eligible sessions on schedule.
  

10. AthenaHealth API

• Function: POST /claims endpoint; configure claims object with required session/billing info.
  

11. WebPT API

• Feature: /claims/submit; map therapist, CPT, diagnosis, and insurance fields for submission.
  

12. NextGen Healthcare API

• Function: EDI Claims submission API; transform ABA therapy event data to required format.
  

13. DrChrono API

• Feature: Claim creation trigger on appointment status change; POST to /claims.
  

14. eClinicalWorks API

• Function: Insurance Claims API; auto-push completed charts as claims.
  

15. Cerner Millennium API

• Feature: FHIR-based Claims endpoint; configure triggers for closed ABA therapy events.
  

16. Epic Systems FHIR API

• Function: Claim.spawn and Claim.update; chain with insurance selection and documentation fields.
  

17. PracticeMate by OfficeAlly (API/SFTP)

• Setting: Batch claim file transfer on claim-ready event; automation via SFTP or practice API.
  

18. Claim.MD REST API

• Feature: Create and submit claims to clearinghouse; requires detailed mapping of therapy codes/fields.
  

19. Change Healthcare API

• Function: Intelligent Claims Management endpoint for EDI 837 submission.
  

20. Meditech Expanse API

• Feature: Automated claim object instantiation; batch submit via API on finalized encounters.
  

21. RelayHealth (McKesson) EDI

• Setting: EDI 837 file submission via SFTP on document completion trigger.
  

22. Availity Essentials API

• Feature: API for real-time claim submission/validation; configure error-handling callbacks.
  

23. Therap Services API

• Function: /insurance_claim/submit; automate from billable activity entries.
  

Benefits

1. Minimizes human data entry and manual claim errors.

2. Shortens reimbursement cycles and speeds up cash flow.

3. Reduces claim rejections by enforcing payer-specific validation.

4. Frees clinical and admin staff for higher-value tasks.

5. Ensures regulatory compliance with HIPAA and industry standards.

6. Provides real-time claim status updates and automated exception alerts.

7. Supports rapid scaling for high-volume ABA therapy practices.