Verification of patient's insurance eligibility and coverage limits
3
Coding of services, procedures and diagnosis
4
Preparation of initial claim
5
Approval: Coding accuracy
6
Transcription and input of coded data
7
Electronically submit claim to payer
8
Monitor status of claim submission
9
Handling payer requests for additional information
10
Approval: Additional Information Provided
11
Evaluate payer's response to claim
12
Manage denials and rejections
13
Address any identified issues and resubmit claim
14
Approval: Claim Resubmission
15
Receipt and posting of payment
16
Generation of patient's statement
17
Payment follow up
18
Monitor and reconcile accounts receivable
19
Processing of write-offs and adjustments
20
Compliance and quality assurance audits
Patient registration and data collection
This task involves registering the patient and collecting all necessary data. It is the first step in the hospital claims processing workflow and plays a crucial role in ensuring accurate and complete medical claims. The desired result is to have all the patient information correctly entered into the system. Key challenges in this task include verifying the accuracy of patient-provided data and ensuring compliance with privacy regulations. Required resources include patient registration forms and access to the hospital's electronic medical record system.
1
Male
2
Female
3
Other
Verification of patient's insurance eligibility and coverage limits
In this task, we verify the patient's insurance eligibility and coverage limits to ensure reimbursement for medical services. The task plays a critical role in preventing claim denials and reducing financial risks. The desired result is to determine the patient's insurance coverage and any potential limitations. Key challenges include dealing with complex insurance plans and communicating with insurance providers to obtain necessary information. Required resources include access to the hospital's database of insurance providers and comprehensive knowledge of different insurance plans.
1
Medical
2
Dental
3
Vision
Coding of services, procedures and diagnosis
This task involves assigning appropriate codes to the services, procedures, and diagnosis related to the patient's medical treatment. Accurate coding is essential for proper claim processing and reimbursement. The desired result is to have all services, procedures, and diagnosis accurately coded. Key challenges include staying updated with coding guidelines and accurately translating medical documentation into codes. Required resources include coding manuals, medical records, and access to coding software or databases.
1
ICD-10-CM
2
CPT
3
HCPCS
4
DRG
1
1
2
2
3
3
4
4
5
5
1
1
2
2
3
3
4
4
5
5
1
1
2
2
3
3
4
4
5
5
Preparation of initial claim
In this task, we prepare the initial claim by compiling all necessary information and documentation. It is a crucial step in the claims processing workflow as it sets the foundation for accurate and timely reimbursement. The desired result is to have a complete initial claim ready for submission. Key challenges include ensuring all required documentation is included and correctly formatted. Required resources include patient medical records, itemized bills, and access to claim forms.
Approval: Coding accuracy
Will be submitted for approval:
Coding of services, procedures and diagnosis
Will be submitted
Transcription and input of coded data
This task involves transcribing and inputting the coded data into the hospital's claims management system. Accurate transcription and data input are crucial for proper claim processing. The desired result is to have all coded data accurately entered into the system. Key challenges include dealing with complex coding systems and ensuring data accuracy during transcription. Required resources include access to the hospital's claims management system and coding manuals.
1
John Smith
2
Jane Doe
3
Mark Johnson
Electronically submit claim to payer
In this task, we electronically submit the claim to the payer, such as an insurance company or government agency. Electronic claim submission is efficient and ensures timely processing and reimbursement. The desired result is to successfully submit the claim electronically. Key challenges include dealing with different claim submission systems and ensuring data accuracy during transmission. Required resources include access to the hospital's claim submission system and knowledge of claim submission protocols.
Monitor status of claim submission
This task involves monitoring the status of the claim submission to ensure timely processing and reimbursement. It is crucial for detecting any issues or delays in claim processing. The desired result is to stay updated on the claim's progress and address any potential issues promptly. Key challenges include dealing with multiple claims simultaneously and effectively communicating with payers for status updates. Required resources include access to the hospital's claim tracking system and effective communication channels with payers.
Handling payer requests for additional information
In this task, we handle payer requests for additional information or documents related to the claim. Prompt and accurate response to payer requests is crucial for uninterrupted claim processing. The desired result is to provide the requested information or documents to the payer in a timely manner. Key challenges include understanding payer requirements and gathering necessary information from appropriate sources. Required resources include access to patient medical records, claim documentation, and effective communication channels with payers.
Approval: Additional Information Provided
Will be submitted for approval:
Handling payer requests for additional information
Will be submitted
Evaluate payer's response to claim
This task involves evaluating the payer's response to the submitted claim. It is essential for identifying claim acceptance, partial payment, denials, or any other actions taken by the payer. The desired result is to assess the payer's response and determine the necessary steps for further claim processing. Key challenges include interpreting payer communication and taking appropriate action based on the response. Required resources include access to the hospital's claim response system and knowledge of payer policies.
1
Accepted
2
Partial payment
3
Denied
4
Pending
Manage denials and rejections
In this task, we manage claim denials and rejections received from the payer. Effective management of denials and rejections is crucial for maximizing reimbursement and minimizing financial losses. The desired result is to resolve claim denials and rejections through appropriate actions, such as appeals or resubmission. Key challenges include understanding denial reasons and taking corrective measures to address them. Required resources include access to denial codes, knowledge of payer appeal processes, and effective communication channels with payers.
1
Review claim documentation
2
Provide additional information
3
Submit appeal
4
Correct coding errors
5
Address eligibility issues
Address any identified issues and resubmit claim
This task involves addressing any identified issues with the claim and resubmitting it for processing. It is essential for ensuring accurate and timely reimbursement. The desired result is to resolve all identified issues and resubmit the claim in a corrected form. Key challenges include identifying the root cause of issues and implementing appropriate corrective measures. Required resources include access to claim documentation, knowledge of claim resubmission protocols, and effective communication channels with payers.
Approval: Claim Resubmission
Will be submitted for approval:
Manage denials and rejections
Will be submitted
Address any identified issues and resubmit claim
Will be submitted
Receipt and posting of payment
In this task, we receive and post the payment received from the payer for the processed claim. Accurate and timely payment posting is crucial for maintaining financial records and closing the claim cycle. The desired result is to accurately record and post the payment received. Key challenges include reconciling payment amounts, identifying payment errors, and ensuring proper application of payments. Required resources include access to financial systems and knowledge of payment reconciliation processes.
Generation of patient's statement
This task involves generating the patient's statement for any outstanding balance due after insurance reimbursement. Accurate and clear patient statements are crucial for transparent billing and payment collection. The desired result is to create a comprehensive patient statement that clearly indicates the balance due. Key challenges include identifying unpaid amounts, accounting for insurance coverage, and ensuring proper statement formatting. Required resources include access to billing systems and knowledge of patient statement generation processes.
Payment follow up
In this task, we follow up with the patient regarding outstanding balance and payment. Prompt and effective payment follow up is crucial for timely payment collection and minimizing bad debt. The desired result is to successfully communicate with the patient regarding the payment due and resolve any outstanding issues. Key challenges include communicating sensitive financial matters and addressing patient inquiries regarding billing. Required resources include access to patient contact information and effective communication channels with patients.
Monitor and reconcile accounts receivable
This task involves monitoring and reconciling the hospital's accounts receivable related to the processed claims. Accurate and up-to-date accounts receivable records are crucial for financial management and reporting. The desired result is to have accurate accounts receivable records that reflect the status of outstanding payments. Key challenges include reconciling payment discrepancies, identifying unpaid claims, and accurately applying payments. Required resources include access to financial systems and knowledge of accounts receivable management processes.
Processing of write-offs and adjustments
In this task, we process write-offs and adjustments for any outstanding amounts that are deemed uncollectible or require corrections. Timely and accurate processing of write-offs and adjustments is crucial for maintaining accurate financial records. The desired result is to properly document and process write-offs and adjustments. Key challenges include determining write-off eligibility and ensuring proper documentation for adjustments. Required resources include access to financial systems and knowledge of write-off and adjustment policies.
1
Review outstanding balances
2
Determine write-off eligibility
3
Process write-offs
4
Analyze A/R aging for adjustments
5
Make necessary adjustments
Compliance and quality assurance audits
This task involves conducting compliance and quality assurance audits to ensure adherence to regulatory requirements and quality standards. Audits play a crucial role in identifying potential risks and areas for improvement in the claims processing workflow. The desired result is to identify and address any compliance or quality issues through corrective actions. Key challenges include staying updated with changing regulations and effectively implementing audit findings. Required resources include access to audit checklists, compliance policies, and effective communication channels with audit teams.
