Claim creation and electronic submission to payers

Purpose

1.1 Automate the creation and submission of insurance claims from allergy clinics to various payers to reduce manual entry, minimize errors, and accelerate reimbursements.
1.2 Extract patient encounter data, convert it to the necessary standardized medical format (e.g., ANSI X12 837), validate information, and transmit electronically to insurance portals or clearinghouses.
1.3 Integrate with EHR/EMR platforms, payer APIs, and clearinghouses to ensure real-time tracking, status notifications, and automatic error flagging for resubmissions.
1.4 Aggregate claim data, match with provider/payer rules, and generate batch or individual electronic claim files.

Trigger Conditions

2.1 Completion of patient visit documentation in EHR/EMR.
2.2 Physician signing off on the encounter note.
2.3 Billing code assignment (ICD-10, CPT, etc.) completed.
2.4 Encounter status marked as "Ready for billing."
2.5 Manual submission by billing staff or automation set to run on schedule (e.g., daily batch).
2.6 Receipt of denial/correction request from payer.

Platform Variants

3.1 Epic EHR
• Feature/Setting: App Orchard API—Outgoing Claims (POST to /claims/submit)
• Description: Configure secure claim data export and real-time posting.

3.2 Cerner Millennium
• Feature/Setting: Code Claims API—Charge Capture (ChargeEntry.AddCharge)
• Description: Send billing events for automated claim preparation.

3.3 athenahealth
• Feature/Setting: Claims API v1/claims
• Description: Programmatic claim submission and status polling.

3.4 AdvancedMD
• Feature/Setting: Claims Submission Endpoint (POST /claims)
• Description: Push prepared claims from integrated system.

3.5 NextGen Healthcare
• Feature/Setting: Claims Interface Module (HL7 outbound integration)
• Description: Automatically forward HL7-based billing data.

3.6 Kareo
• Feature/Setting: Kareo API—SubmitClaim
• Description: Map fields and trigger electronic claim submission.

3.7 DrChrono
• Feature/Setting: Claims API (POST /claims)
• Description: Automated submission and batch status updates.

3.8 Practice Fusion
• Feature/Setting: Practice Fusion Partner API—Claim Submission
• Description: Partner endpoint for claim handoff to billing solution.

3.9 Greenway Health
• Feature/Setting: Prime Suite API—e-Claims Export
• Description: Export batch claim files on encounter close.

3.10 OpenEMR
• Feature/Setting: eClaim X12 837 Exporter
• Description: Automated generation and SFTP upload of batch files.

3.11 Trizetto Provider Solutions
• Feature/Setting: EDI Submission—X12 Claim Upload
• Description: Configure secure SFTP/API endpoint for claim intake.

3.12 Change Healthcare
• Feature/Setting: Claims Management API—/claims/submit
• Description: Integrate claim file transfer and status retrieval.

3.13 Availity
• Feature/Setting: EDI Clearinghouse API—Claim Submission
• Description: Push claims and receive real-time validation feedback.

3.14 Office Ally
• Feature/Setting: Secure FTP Claims Upload
• Description: Schedule automated file transfer for claim batch processing.

3.15 RelayHealth (McKesson)
• Feature/Setting: Relay Exchange API—Claim Submission
• Description: Automated transmission, error checking, and acknowledgment retrieval.

3.16 Waystar
• Feature/Setting: Waystar API—Claim Submission & Tracking
• Description: Send claims, monitor rejections, and pull status updates.

3.17 Medisoft
• Feature/Setting: eClaim Export Utility
• Description: Triggered export/upload on schedule or claim batch closure.

3.18 Allscripts
• Feature/Setting: Allscripts API—E-Claim Integration
• Description: Map fields, automate outbound submission.

3.19 eClinicalWorks
• Feature/Setting: eBO Claims Module API
• Description: Submit claims programmatically with payer mapping rules.

3.20 HL7 Integration Engine (Mirth Connect)
• Feature/Setting: Transformation Channel—837 Outbound
• Description: Automate transformation and routing of claim files to payers/clearinghouses.

Benefits

4.1 Eliminates manual data entry and duplicate work in allergy & immunology billing operations.
4.2 Reduces costly errors and accelerates payment cycles through validation and pre-submission checks.
4.3 Ensures 24/7 claim submission and tracking without human oversight.
4.4 Enables real-time feedback on acceptance, denials, or data issues.
4.5 Scales across multiple payer platforms and specialty clinics with minimal incremental setup.
4.6 Integrates with analytics to identify trends, denial causes, and optimize future submissions.