Flag and escalate claim denials or errors

Purpose

1.1. Automate the identification of insurance claim denials or processing errors within addiction treatment centers.
1.2. Immediately flag irregularities and route them to the responsible compliance, billing, or management staff for rapid resolution.
1.3. Minimize manual review, accelerate appeals or corrections, reduce lost revenue, and ensure rapid attention to problematic claims.
1.4. Maintain regulatory compliance and improve patient and payer experience through efficient insurance cycle management.

Trigger Conditions

2.1. Claim denial received from payer EDI or clearinghouse response.
2.2. Error code or “denied” status detected in EHR/insurance module.
2.3. Claim aged beyond X days without adjudication.
2.4. Payment does not match expected contracted rates or benefits.
2.5. Human override: staff clicks “flag for review” in EHR.

Platform variants

3.1. Epic Systems
• Feature/Setting: Use Hyperspace EHR Integration; Configure Chronicles database rule for claim status monitoring; API: Interconnect FHIR for real-time status push.
3.2. Cerner
• Feature/Setting: Registration & Billing; Discern Analytics rule for claim error triggers.
3.3. Salesforce Health Cloud
• Feature/Setting: Health Cloud Insurance Module; Configure OmniStudio DataRaptor to watch claims; API: Insurance Claims resource endpoint.
3.4. NextGen Healthcare
• Feature/Setting: Claims Management Center; Set automation rules for “Denied” status; API: EDI Remittance endpoint.
3.5. Allscripts PM
• Feature/Setting: EDI Automation Rules; Web Services API: getClaimStatus, on-response alert.
3.6. Kareo
• Feature/Setting: Claims Scrubber & Payments Feed; API: /claims/webhooks/denials.
3.7. Athenahealth
• Feature/Setting: Workflow Rules Engine—Claim Outcomes; API: /claims/v1/denials.
3.8. Greenway Health
• Feature/Setting: Revenue Cycle Dashboard, Alert Setup; API: /api/claimdenial.
3.9. eClinicalWorks
• Feature/Setting: eBO Alerts; use API: getClaimsDenial.
3.10. DrChrono
• Feature/Setting: Billing Denials View; API: /claims/denials list.
3.11. Waystar
• Feature/Setting: Claim Monitoring Ruleset; API: Denial EDI hook.
3.12. Availity
• Feature/Setting: Remit Alerts; API: Real-time Notification Webhook.
3.13. TriZetto
• Feature/Setting: Denial Management Work Queues; API: On-claim-Denial notification.
3.14. Meditech Expanse
• Feature/Setting: Claims Scrubber and Flag rule; API: Outbound Denial alert via Event Hub.
3.15. PracticeSuite
• Feature/Setting: Denied Claims List; API: /api/v2/billing/claim-denials.
3.16. SimplePractice
• Feature/Setting: Payment Reports; API: EOB Webhook integration.
3.17. AdvancedMD
• Feature/Setting: Claims Center Workflow Alert; API: /edi/claims/denied.
3.18. OpenEMR
• Feature/Setting: Electronic Billing Module Ruleset; API: x12_835_denials.
3.19. Inovalon
• Feature/Setting: Denial Analytics Engine; API: claim_denial_feed.
3.20. Microsoft Power Automate
• Feature/Setting: Automate with “When a record is updated” (Dataverse); Connector: FHIR, HL7, or EHR APIs for event-based trigger.
3.21. Zapier
• Feature/Setting: Webhook / Claims App Integration; Trigger: EDI Denial.
3.22. Slack
• Feature/Setting: Incoming Webhook to “Billing-Compliance” Channel; trigger on new flagged denial.
3.23. ServiceNow
• Feature/Setting: Flow Designer; Set “Insurance Denial” Incident type created on EHR webhook trigger.
3.24. PagerDuty
• Feature/Setting: Alert Rules; Trigger Escalation Policy on API call from claim system.

Benefits

4.1. Immediate, automated notification reduces claim cycle delays.
4.2. Prevents loss of revenue due to unattended denials or errors.
4.3. Ensures regulatory compliance with audit-ready traceability.
4.4. Frees staff time for higher-value activities.
4.5. Enables rapid resolution or correction, improving relationships with payers and patients.