Claims Management Module
Complete claims lifecycle management from submission through adjudication, payment, and reconciliation — supporting professional (CMS-1500), institutional (UB-04), and dental claim types.
Organization Relevance
How It Works
Claims enter via EDI 837 transactions, OCR-scanned paper claims, or direct entry. The system validates claims against eligibility, authorization, and benefit rules. The adjudication engine applies pricing from fee schedules, coordination of benefits (COB), and audit rules. Approved claims generate payment through ERA/EOB. The fraud detection module uses rule-based and ML algorithms to flag suspicious patterns. All claims maintain a complete audit trail.
Requirements
- EDI 837 Professional/Institutional/Dental connectivity
- ERA 835 payment generation capability
- Fee schedule and contract rate tables
- Provider and member eligibility data
- Fraud detection rule engine
- Compliance with state prompt-pay laws
Target Audience
Claims Processors, Claims Examiners, SIU/Fraud Teams, Finance Teams, Provider Relations
Pages (16)
| Page | Purpose | Key Features |
|---|---|---|
| Claims Dashboard | Real-time claims processing overview with volume, turnaround, and financial metrics | Processing metrics, Queue depth, Payment summary, Aging analysis |
| Claims Adjudication | Automated and manual claims adjudication workflow with benefit application | Auto-adjudication, Manual review queue, Edit resolution, Payment calculation |
| Audit Rules | Configure claims editing and audit rules for accuracy and compliance | Rule library, CCI/MUE edits, Custom rules, Rule effectiveness |
| Capitation Claims | Manage capitated claims processing and reconciliation | Capitation processing, Encounter tracking, Reconciliation, Payment calculation |
| Coordination of Benefits | COB determination and processing for members with multiple coverage | COB order determination, Other insurance tracking, Savings calculation, COB letter generation |
| Dental Claims | Dental claim processing with ADA code support | Dental claim entry, ADA code validation, Benefit application, Orthodontic tracking |
| Claims Disputes | Provider and member claims dispute resolution workflow | Dispute intake, Investigation workflow, Resolution tracking, Communication log |
| EDI 837 Processing | Inbound EDI 837 claim file processing and validation | File ingestion, Syntax validation, Claim parsing, Error reporting |
| ERA/EOB | Electronic remittance advice and explanation of benefits generation | ERA generation, EOB creation, Payment details, Adjustment codes |
| Export/Import | Bulk claims data import and export for migration and reporting | Batch import, Export formats, Validation rules, Progress tracking |
| Fraud Detection | Claims fraud, waste, and abuse detection using rules and analytics | Rule-based detection, Pattern analysis, Alert generation, Investigation workflow |
| Claims History | Searchable claims history with full detail and audit trail | Advanced search, Claim detail view, Audit trail, Related claims |
| Institutional Claims | UB-04 institutional claims processing for facility billing | UB-04 processing, Revenue code validation, DRG pricing, Outlier detection |
| OCR Processing | Optical character recognition for paper claim digitization | Document scanning, OCR extraction, Field mapping, Quality verification |
| Claims Pricing | Fee schedule and contract-based claims pricing engine | Fee schedule lookup, Contract rate application, Allowed amount calculation, Pricing history |
| Professional Claims | CMS-1500 professional claims processing for physician services | Professional claim entry, CPT/HCPCS validation, Modifier handling, Place of service rules |
API Integrations
X12 837 Claim Submission (P/I/D)X12 835 Remittance AdviceX12 276/277 Claim StatusClaims search and inquiry APIFraud alert notification API
Referenced Resources
X12 837/835 Implementation GuidesCMS-1500 and UB-04 form specificationsNAIC Model Act for Claims ProcessingCMS National Correct Coding Initiative (NCCI)
Expected Results
Accurate, timely claims adjudication with fraud prevention, regulatory compliance, and transparent payment processing. Supports auto-adjudication rates exceeding 85%.