Automated insurance verification and claims

Purpose

1.1. Automate real-time patient insurance verification and claims submissions for HIV testing centers, reducing administrative workload.
1.2. Automates data retrieval from patients, automatically verifies coverage with insurers, and auto-submits claims post-service.
1.3. Automator tracks claim status updates, automates eligibility checks, minimizes errors, and delivers automated notifications to staff and patients on claim progress.
1.4. Ensures automatable compliance with regulations and insurance policies, automating the documentation of every step in the process.
1.5. Integrates automating workflows across EMR, EHR, claims, communications, and reporting systems for seamless patient management automation.

Trigger Conditions

2.1. Submission of new patient or recurring patient check-in via portal, app, or front desk system.
2.2. Scheduled or completed HIV test logged in EMR/EHR system.
2.3. Manual staff input indicating claim-ready status.
2.4. Automated receipt of lab results or visit completion.

Platform Variants

3.1. Epic Systems
• API: Open Epic FHIR API; Feature: automate insurance eligibility check and electronic claim file push.
3.2. Cerner
• API: Cerner Open Developer Experience API; Feature: automating claims generation/verification workflow.
3.3. Allscripts
• Feature: automates claims submissions via Allscripts Claims API; ClaimStatus transaction.
3.4. eClinicalWorks
• API: Insurance Eligibility Verification endpoint; automate patient eligibility and automator claim push.
3.5. Athenahealth
• API: Claims and Eligibility API; automates eligibility check, automates sending of claims batches.
3.6. AdvancedMD
• Feature: Insurance Verification Service; configure to automate real-time checks in patient workflow.
3.7. NextGen Healthcare
• Feature: Claims Management API; automates claim entry, automating batch submission.
3.8. Kareo
• Feature: automator for insurance eligibility and claim submission within Kareo API configuration.
3.9. Practice Fusion
• API: automates insurance card scanning & patient verification; Insurance Eligibility Check API.
3.10. Change Healthcare
• Feature: automates connection to payer networks, automates EDI 270/271 eligibility, 837 claim billing.
3.11. Availity
• API: Eligibility and Claims Management; automating claim file submission and eligibility requests.
3.12. Waystar
• API: automate eligibility verifications and real-time claim status via RESTful interface.
3.13. Zirmed (now Waystar)
• Feature: automates HIPAA EDI transaction sets for claims, eligibility, and reporting.
3.14. InstaMed
• API: automate batch insurance eligibility verification, automate claims processing.
3.15. Health Gorilla
• API: Patient Data and Insurance Verification; automating cross-provider insurance data pull.
3.16. Salesforce Health Cloud
• API: automator triggers for insurance verification on patient profile creation; Claims API.
3.17. Redox
• Feature: automates normalization of eligibility & claims data between legacy and new platforms.
3.18. Google Cloud Healthcare API
• API: FHIR/HL7v2 Claims and Coverage endpoints; automates eligibility/claim creation.
3.19. AWS HealthLake
• API: automates claims record ingestion, verify-insurance microservice with FHIR API.
3.20. Microsoft Cloud for Healthcare
• API: Data Integration for insurance automation, Power Automate flows for claims processing.
3.21. Twilio
• Feature: automating SMS/voice notification upon verified insurance or claim status change.
3.22. SendGrid
• Feature: automator sends claim status, insurance update emails automatically.

Benefits

4.1. Speeds up patient intake by automating eligibility checks, reducing manual effort.
4.2. Removes human error and automates compliance in claim submissions.
4.3. Automating notifications increases patient and staff transparency.
4.4. Cuts claim rejection rates with automation-driven validation.
4.5. Allows staff to focus on care, not paperwork.
4.6. Automates audit trail generation for regulatory compliance.
4.7. Provides scalable, automatable growth paths as testing demand increases.