Denied medical claims are one of the complex challenges causing a huge sum of reimbursement losses for healthcare providers in the US.

Minor coding mistakes and complex nature of ICD-10 coding are the pressing issues faced by US healthcare system.

Healthcare providers in the US need an advanced claim check system that automatically checks the medical reviews before submission and generate finalized error-free medical claim read for the submission.

A US-based healthcare company wanted to create an automated and cloud-based claim review system to identify errors and avoid long turn-around time. Patient authorization, Pokitdot APIs, and claim scrubbing based on Aetna guidelines helped them to enhance the claim processing workflow. The key requirement was to perform Pokitdok X12 API Claim Status Call to export patient’s data and validate the claim using the payer guidelines.

The client needed an automated post-payment claims review model to ensure the accuracy of the adjudicated claims.

We began working on the system flow diagram to ensure the right workflow of the claim check that would allow providers as well as patients to get their claims checked instantly.

We divided the entire system into two different modules; they are User Module and Explanation of Review (EOR) module.

The proposed modules for the backend were OCR-based 'Form 1500 P' or 'Form 1500 I / UB04' scraping and data gathering.

OSP built separate prototypes for all the distinct modules that made the whole claim check system. Before the beginning of the project, we designed an in-depth system architecture which later helped us to streamline the overall software development life-cycle process. We decided to design the system in such a way that either the patient or the provider can upload the EOB upon the patient's request.

On submitting the claim status check form, the system would make an API call to Pokitdot to fetch the claim status of the medical claims.

The data received from the Pokitdot would be populated on a pre-designed EOR form.

The system then checks the claim with the AETNA's guidelines and codes and then add comments to the EOR form.

On completing the review, the system would generate the completed EOR form to show errors and issues.

OSP’ next-gen claim check review system gives Pokitdok X12 API claim status Call via insurance carriers specific ICN number to create an XML-formatted CMS 1450 form. Our system includes a claims scrubbing tool to validate XML-formatted CMS 1450 against specified Aetna guidelines. In our system, the data from the 'Form 1500 P' or 'Form 1500 I / UB04' is automatically pulled out to get the ICD or CPT codes to be checked against various government-laid guidelines such as,

• DC Official Coding Guidelines
• Coding Guidelines for Inpatient Procedures
• NCCI
• Physician Fee Schedule

Our solution helped to reduce the time required for the entire claim reviewing process from 7 weeks to less than 12 hours.

The turnaround time for error rectification was decreased to less than 2 minutes.

The system helps to generate 100% error-free EORs that are totally ready for submission.

OSP claim check solution offers the prediction for financial differences for any specific treatment in two different states.

According to the American Academy of Family Physicians (AAFP) report, around 5-10% average claim denial rate is faced by the US healthcare industry currently. OSP' automated claim check review system played a vital role in reducing the claim denial rate for our client. Our web-based claim review system replaced the conventional manual claim check system which was more error-prone. With OSP' advanced claim check review, the client can easily upload standard EOB forms, avoid claim errors and reduce turnaround time.