Patient Management AutomationAutomated Insurance Verification and Eligibility Checks for Pediatric Patient Management in Children's Hospitals
1.1.1. Automatedly validate patient insurance data during intake to streamline eligibility confirmation for treatments, reducing manual labor and data entry errors.
1.1.2. Automates retrieval of policy details, coverage limits, patient co-pay/deductibles, and network participation in real time with insurance providers.
1.1.3. Ensures proactive eligibility before appointments or admissions, automating communication of issues detected for swift resolution.
1.1.4. Automates checking of high-priority insurances for specialized pediatric cases, reducing claim rejections and enhancing patient experience.
1.2. Trigger Conditions
1.2.1. New patient registration event in EMR or EHR system.
1.2.2. Scheduled appointment creation with pending insurance field.
1.2.3. Existing patient insurance updated or expiring soon.
1.2.4. Immediate eligibility check requested by front-desk or clinical staff.
1.2.5. Recurring nightly automation for batch verification of upcoming appointments.
1.3. Platform Variants
1.3.1. Epic Systems (EMR)
• Feature/Setting: Connect via HL7 FHIR API to automate insurance eligibility query; configure "CoverageEligibilityRequest" resource.
1.3.2. Cerner (EMR)
• Feature/Setting: Automate using Cerner Open Developer Experience (code eligibility automation with "Coverage Eligibility" API endpoint).
1.3.3. Athenahealth
• Feature/Setting: Use "insurance eligibility verification" API in Workflow Automation settings; trigger upon patient scheduling.
1.3.4. Allscripts
• Feature/Setting: Integrate Allscripts API for automated eligibility checks by configuring "Patient.Inquiry" workflow triggers.
1.3.5. NextGen
• Feature/Setting: Automate via NextGen "Eligibility Checking" service API and scheduling module settings.
1.3.6. Availity
• Feature/Setting: Leverage "Eligibility & Benefits" API, automating REST POST requests on patient intake.
1.3.7. Change Healthcare
• Feature/Setting: Use "Eligibility and Benefits Verification" API automation; configure endpoints for real-time submission.
1.3.8. Experian Health
• Feature/Setting: Automate eligibility checks using "Eligibility Verification" API integrating batch or real-time queries.
1.3.9. Redox
• Feature/Setting: Configure automated flows with Redox "Eligibility" data model for EHR interoperability.
1.3.10. HL7 FHIR Server
• Feature/Setting: Automate submission of FHIR "CoverageEligibilityRequest" resources and polling for "CoverageEligibilityResponse."
1.3.11. Salesforce Health Cloud
• Feature/Setting: Utilize Health Cloud Data Model automation—automate API "Insurance Plan Verification" actions.
1.3.12. Meditech
• Feature/Setting: Automate scripted events via API and "Eligibility Verification Integration" interface.
1.3.13. Greenway Health
• Feature/Setting: Enable "Insurance Eligibility" in API configuration to automate checks during scheduling.
1.3.14. eClinicalWorks
• Feature/Setting: Configure eBO Automation for automated "Eligibility Processing Report" runs after registrations.
1.3.15. SimplePractice
• Feature/Setting: Automate insurance verification by configuring automated eligibility API pull at booking.
1.3.16. AdvancedMD
• Feature/Setting: Use "Insurance Eligibility Verification" feature in automated workflow rules for new entries.
1.3.17. TiDB (open-source systems)
• Feature/Setting: Automate extract-transform-load flows for verified insurance data when patients are onboarded.
1.3.18. Microsoft Power Automate
• Feature/Setting: Build automated flows using "HTTP" actions to call insurance APIs when records are created.
1.3.19. SAP Health
• Feature/Setting: Configure automated API calls for "Eligibility Check" in patient master data automation.
1.3.20. MuleSoft
• Feature/Setting: Automate orchestration with "Healthcare Toolkit" prebuilt connectors for eligibility APIs.
1.3.21. RPA tools (UiPath, Automation Anywhere, Blue Prism)
• Feature/Setting: Automate manual screen scraping or direct API calls to insurance portals at scheduled times.
1.4. Benefits
1.4.1. Automates routine validation tasks, reducing clerical workload and human error.
1.4.2. Enhances speed and reliability of eligibility checks for critical pediatric cases.
1.4.3. Improves patient and guardian experience through proactive, accurate automation.
1.4.4. Automating insurance verification raises claim acceptance rates and revenue cycle efficiency.
1.4.5. Supports compliance by automating secure, audit-trailed insurance verification processes.
1.4.6. Automator-driven integrations enable scalable, adaptable workflows across diverse platforms in the pediatric hospital setting.