Automated Medicaid/private insurance claims submission

Purpose

1.1. Enable secure, timely Medicaid/private insurance claims for services rendered, reduce manual errors, and accelerate reimbursements.
1.2. Ensure compliance with CMS, HIPAA, and payer-specific protocols, handling eligibility checks, claim creation, status tracking, and denials management.
1.3. Automate generation, submission, follow-up, and reconciliation for all claims to streamline revenue cycle.

Trigger Conditions

2.1. Completion of client session/service in practice management software.
2.2. New billing record generated by EHR or attendance tracking system.
2.3. Manual data upload or API signal indicating ready-to-bill encounters.
2.4. Updates or changes to insurance or eligibility status in patient profile.
2.5. Recurring scheduled claim batch (e.g., daily at 8 PM).

Platform Variants

3.1. PracticeSuite
• Feature/Setting: "Claims Submission API" — Configure automated claim export to X12 837.
• Sample: API key, endpoint URL, mapping rules.
3.2. Kareo
• Feature/Setting: "Clearinghouse EDI Link" — Auto-upload charges for payers.
• Sample: Enable EDI, input practice NPI.
3.3. Availity
• Feature/Setting: "Batch Claims Submission" — Schedule claim file uploads.
• Sample: SFTP credentials, payer list.
3.4. Office Ally
• Feature/Setting: "Direct Data Entry (DDE) API" — Integrate billing system for claims.
• Sample: API token, format: 837 Professional.
3.5. Waystar
• Feature/Setting: "Claim Management REST API" — Automate claim feeds.
• Sample: OAuth2 credentials, transmission frequency.
3.6. SimplePractice
• Feature/Setting: "Insurance Automation Workflow" — Set up insurer rules for auto-submission.
• Sample: Insurer rules, assign default billing code.
3.7. NextGen Healthcare
• Feature/Setting: "Claims Integration Engine" — Map EHR billing output to 837P.
• Sample: Transport protocol, destination, and formatting.
3.8. Athenahealth
• Feature/Setting: “Billing API—Claim Submission” — Auto-post encounters to payers.
• Sample: Claim object JSON, authentication key.
3.9. AdvancedMD
• Feature/Setting: "Automated Insurance Billing" — Schedule batch claims from EHR.
• Sample: Date/time rules, payer mapping.
3.10. Quadax
• Feature/Setting: "X12 Gateway API" — Accept claims from internal systems.
• Sample: Trading partner ID, X12 837 setup.
3.11. Greenway Health
• Feature/Setting: "Intergy Billing System" — Automate claim creation on encounter close.
• Sample: Patient status triggers, payer auto-routing.
3.12. Change Healthcare
• Feature/Setting: "Claims Connect API" — Real-time insurance claim uploads.
• Sample: REST hook, configure endpoint.
3.13. Experian Health
• Feature/Setting: "Eligibility and Claims Automation" — Link EHR to claims adjudication.
• Sample: Secure FTP, payer number, encounter batch.
3.14. eClinicalWorks
• Feature/Setting: "Billing Claims API" — Export encounters to clearinghouse.
• Sample: Provider ID, EHR trigger.
3.15. Medisoft
• Feature/Setting: "EDI Automation Service" — Batch and transmit insurance forms.
• Sample: Scheduler, payer parameter.
3.16. TriZetto Provider Solutions
• Feature/Setting: "Claims API" — Ingest formatted claims via web service.
• Sample: Practice credentials, “auto-submit” flag.
3.17. Azalea Health
• Feature/Setting: "Clearinghouse Integration" — Auto-push billing files to payers.
• Sample: Clinic account, batch frequency.
3.18. Apache Camel (integrator)
• Feature/Setting: "X12 Route Component" — Orchestrate intake/dispatch of claim files.
• Sample: EHR source, payer destination URIs.
3.19. Jitterbit
• Feature/Setting: "Healthcare Connectors" — Move HL7/X12 files from EHR to payer.
• Sample: EHR path, payer credentials.
3.20. MuleSoft
• Feature/Setting: "Healthcare Integration Template" — Build claim pipelines using DataWeave.
• Sample: Flow triggers, auth settings.
3.21. Health Gorilla
• Feature/Setting: "Clinical Data Network API" — Push claims to payers.
• Sample: Facility ID, frequent claim polling.
3.22. HL7 FHIR servers
• Feature/Setting: "Claim Resource Endpoint" — Convert and transmit insurance claims.
• Sample: FHIR credentials, mapping rules.
3.23. Cerner
• Feature/Setting: “Billing Management API” — Auto-send finalized encounters.
• Sample: Termination event, payer links.
3.24. Qualifacts
• Feature/Setting: “Claim Generation Task” — Trigger X12 creation after documentation complete.
• Sample: Electronic billing profile, transmission schedule.

Benefits

4.1. Cuts revenue delays by immediate submission of compliant claims.
4.2. Minimizes human errors, rejections, and administrative overhead.
4.3. Enables rapid follow-up on denials or resubmissions.
4.4. Ensures seamless integration with existing EHR and PM solutions.
4.5. Scales reliably for both Medicaid and private payers, supporting center growth.