Validation and processing of insurance claims

Purpose

1.1. Automate and standardize validation, submission, and reconciliation of ambulance insurance claims, reducing manual errors and ensuring regulatory compliance.
1.2. Streamline multiple inputs (ePCRs, transport logs, patient consents, billing codes), cross-check eligibility, validate CPT/ICD-10, and deliver claims to insurers with status feedback.
1.3. Reconcile responses (approvals, rejections, payment advices), trigger appeals or follow-ups, and sync resolved records to billing/ERP/EMR systems.

Trigger Conditions

2.1. New ambulance encounter logged in ePCR or dispatch system.
2.2. Patient transport completed and discharge note closed.
2.3. Billing office initiates claim preparation or uploads batch claims.
2.4. Payment remittance or insurer correspondence received.

Platform Variants

3.1. Salesforce Health Cloud
• Feature/Setting: Flows with Insurance Claims custom object; trigger on record create/update for ePCR; configure Process Builder for claim submission.
3.2. Microsoft Power Automate
• Feature/Setting: Pre-built insurance connectors; schedule Flows on new SharePoint ePCR or intake files; configure branching for claim status.
3.3. Epic Bridges API
• Feature/Setting: HL7/FHIR extraction of transport claims; configure event notification for encounter close.
3.4. Cerner Open Developer Experience (CODE)
• Feature/Setting: Use Cerner FHIR APIs for encounter and billing item pull; automate claim payload assembly.
3.5. Greenway Health Intergy API
• Feature/Setting: Activate Insurance Claim endpoint; auto-post ePCR to payer portal.
3.6. AdvancedMD Claims API
• Feature/Setting: Submit batch claims with REST API and receive ERA/835 remittances.
3.7. Kareo API
• Feature/Setting: Claims.create endpoint for CPT/ICD verified submissions; monitor rejections with webhook.
3.8. Availity API
• Feature/Setting: SubmitClaim endpoint; real-time payer validation on patient and eligibility.
3.9. Change Healthcare API
• Feature/Setting: Medical Network APIs for claims; automate payer response monitoring.
3.10. Emdeon (Change Healthcare) Claim Submission
• Feature/Setting: SFTP/API for batch claim transmission and 277/835 reconciliation.
3.11. R1 RCM Claim Solutions
• Feature/Setting: Event-based trigger on ambulance dispatch record completion; configure API integration.
3.12. WebPT Claims Integration
• Feature/Setting: WebPT SMART integration for ambulance claim upload; monitor insurance eligibility response.
3.13. QuickBooks Online
• Feature/Setting: API for invoice and payment sync from resolved claims; configure webhook for new paid records.
3.14. SAP ERP HANA
• Feature/Setting: Activate healthcare insurance claim workflow; map resolved insurance payments to general ledger.
3.15. Oracle Cloud Healthcare
• Feature/Setting: API-triggered process for new ambulance claim entries; auto-post insurer responses.
3.16. Guidewire ClaimCenter
• Feature/Setting: API for intake and update of EMS claim records; push notifications for status changes.
3.17. Meditech Expanse
• Feature/Setting: Integration toolkit for claim item import/export; FHIR automation for claim lifecycle.
3.18. NextGen Healthcare
• Feature/Setting: EDI Claims Interface; map ground ambulance modifiers and validate codes pre-submission.
3.19. AWS Lambda + Amazon S3
• Feature/Setting: Trigger Lambda on new claim document upload to S3; run validation or policy logic via API callouts.
3.20. Google Cloud Healthcare API
• Feature/Setting: Ingest FHIR documents; parse and route ambulance claims to payer channels.

Benefits

4.1. Reduces time spent on manual claim preparation and submission.
4.2. Improves first-pass claim approval rates via automated code/eligibility validation.
4.3. Enhances compliance by automating tracking and audit trails of every claim interaction.
4.4. Enables near real-time insights and escalations on claim denials and underpayments.
4.5. Ensures compatibility with diverse EHR, billing, and insurance platforms.