To request more information about Payer Claims Assistant or to schedule a demonstration, please contact us here.

For a more information on the state of medical claims denials, please download our white paper, The Medical Claims Denial Cycle.

What does Payer Claims Assistant do?

Our goal is to reduce or eliminate medical claim denials.

The Payer Claims Assistant is designed to work with your current payer claims processing environment to improve approval rates for a given payer based on historical claim processing knowledge. The Payer Claims Assistant can be used stand-alone.

The Payer Claims Assistant:

  1. Suggests claim codes (ICD, DSM, CPT, HCPCS) based on provider notes
  2. Using knowledge of current and past claims for each payer, determines if the claim as written will likely be approved or denied
  3. Suggests possible changes to the claim to improve the chance of approval
  4. Assists in writing letters of justification if the claim is denied
  5. Adapts to changes in payer claim adjudication rules

For more information about Payer Claims Assistant, please see here.

Why Payer Claims Assistant?

Products that support the provider’s medical claims processing, focus mainly on establishing claim handling process workflow and checking claims for errors. This is important.

However, once errors such as patient name, subscriber information, and missing diagnosis/procedure codes are handled, you may still need to correct medical information cited as the reason for claim denial, (e.g. “insufficient medical necessity”).

The Payer Claims Assistant (PCA) provides proactive automated assistance to reduce payer claim denials citing inconsistency of medical information, use of non-covered drugs or insufficient medical necessity.

Using information from your EMR (or entered by hand), PCA identifies the claims that are likely to be denied. PCA then suggests various changes to the medical information that will improve the chance of claim approval for the identified payer.

PCA uses past payer-specific claims/results along with a detailed understanding of medical terms and applicable coding standards (e.g. ICD9, ICD10, DSM, CPT, HCPCS…) to quickly guide providers through the process of producing medically consistent well documented claims.

PCA also recommends possible changes to medications in line with those previously approved by the payer for the given (similar) diagnosis and history.

If the claim is rejected and a reason is given, PCA will guide the provider to amend the claim for resubmission and/or help the provider compose a letter of justification.