Medical Claims Management

Medical claims management is the process by which insurance payer companies assess claims and determine their validity and the extent of coverage. Software for medical claims improves the speed and efficiency of the entire process of claims management in healthcare. This is possible through automation. Automating all the repetitive and manual tasks increases the overall speed of healthcare claim processing and decreases mistakes. In other words, increased speed and reduced mistakes ultimately result in greater productivity. As a result, fewer, if any, fraudulent claims are getting approved.    

Let’s build your project

Explore Medical Claims Management

Claims integration is the best way to provide automated and easy access to their health records and medical claims in one place. Healthcare claims management is a highly complex process. It can be made simple by customized medical claims processing software with the claim integration system. Tailored medical billing systems with claims integration allow easy access to a digital archive of all the records, including medical, dental, prescription, and vision services in the USA.

OSP’s solution to claim processing system in healthcare can help you to track bills, payments, and annual deductibles automatically. We customize billing claim medical software to simplify quality control maintenance, to maximize productivity & compliance. Multiple models of claims integration with patient accounting make our tailored claims software solutions comprehensive and flexible. Our Tech experts in the USA engineer claim management solutions with claims integrations for claim submission to payor notification dates, payor acceptance, and rejection data, claims status, eligibility, ERA and denial information.

A medical claim billing software needs proficient claims review management to support the accurate coding of claims that result in fair, and transparent payment policies. An ICD-10-compliant medical claims management software that evaluates claims information helps providers in the USA to decrease the rate of denials. Top-notch claim administration software solutions have claim review management systems that include CPT/HCPCS procedure codes to identify coding errors and conflicts to make recommendations for correction for both professional as well as facility claims.

OSP can program health claims processing solutions with pre-configured coding rules. We create next-gen claim software solutions that provide the clinical foundation of rules and logic essential for intelligent claim edit results. Through medical claims management solutions, we strive to improve provider payment transparency by sharing claim edit rules, source data, and complete clinical rationale for potential claim edits with providers through your payer’s website.

Reporting is one of the most underrated yet essential modules in a working revenue cycle management system. To better your claims management healthcare solutions finding the common errors and mistakes is important. OSP can help providers in the USA with easy-to-use and intuitive reporting dashboards that help to visualize the most common reasons for claim denials and rejections. We customize the healthcare claim administration software to enhance your reporting capabilities and help you plug the revenue leakage across your revenue cycle.

We program health claims software with a customizable reporting system to analyze the claims data in your preferred format with a modern, wizard-like setup experience. Our tailored medical claims management system ensures robust data feeds to enable holistic claims understanding through a big-picture view of your data.  OSP can engineer healthcare claims management software with smart reporting to achieve real-time performance management and learn new ways to boost revenue. Through our made-to-order medical claim software, you can easily build your reports to make cash forecasting and productivity management.

Electronic Data Interchange (EDI) is the sending and obtaining electronic data using technology. For claims submission, a standalone EDI system is required. Especially for an 837 file that contains patient claim information. For billing and claims management, good quality EDI system allows you to quickly and easily automate the claims processing. It helps in minimizing revenue leakage, boosting clean claim rates, and drive down unproductive manual systems.

We customize medical insurance claims processing solutions with next-gen EDI systems the can process millions of enrolments, medical claims, and other EDI transactions across the USA quicker than any manual system or clearinghouse. Health claims management process is made compliant by implementing the SNIP levels 1 – 7 and getting CORE CAQH compliance. The flow of your EDI can be easily monitored, controlled, and maintained with executive dashboards, smart analytics, and databases, making your healthcare claims management system full proof.

Medical Claims solutions require claims status management to automate the follow-up process for commercial payers by accelerating the provider’s timeline for receiving payment while reducing the cost-to-collect. It is a highly time-consuming and complicated process, made further difficult with limited access to claims adjudication status. By automating the claims status management, the manual claims status checks can be eliminated in medical claims management.

OSP can engineer healthcare claims software that automates the claims status management by retrieving the claims status data from the payers and generate a list of approved, rejected, and denied claims.  OSP’ made-to-order medical claim processing Solution in the USA helps to eliminate the efficiencies of manual status searches to gather more actionable details. Our custom medical claims management healthcare solutions help to lower A/R days resulting from denied or unpaid claims not being worked in time. By streamlining the claims status management, OSP’ custom-made claim administration software solutions prove highly beneficial for providers in the USA.

Traditional medical insurance claims processing software requires manual payment postings wasting time and resources that can be utilized on primary processes. An automated remittance management module in claims management software help to manage the entire remittance process and streamline downstream processes to save time and money. Our medical claim management with top-notch remittance management helps you retrieve and capture every ERA transaction from the payors in the USA, eliminating the time-consuming follow up when files are not available.

OSP’s claim management solutions stand to resolve issues created by inconsistencies across payor ERA files. It eliminates the need for manual correction often necessary after automated posting processes are complete. Remittance data is posted through batch or key emulation capabilities, including final payments and contractual adjustments, as well as patient liability information and reason codes. Following up on outstanding payments and remittance advice is made easy with our tailored medical insurance claims software solution.


An insurance company would deal with dozens or even hundreds of claims each day. In light of this, some are bound to be fraudulent but still get approved. Estimates show that insurers lose several million dollars to such claims. However, the claim management software that OSP can build will improve the efficiency and accuracy of the claims assessment process. As a result, it will become easier for payers to detect suspicious claims and reject them.

Software for healthcare claim processing accelerates and optimizes the entire process of claims management significantly. This means that payers can assess a higher number of claims each day without any increase in their staff strength. In other words, claims processing software enables them to do more with less. By increasing productivity without an increase in overhead, claim processing software ultimately results in higher payer revenues.

Due to several unforeseen factors, processing claims can take longer than expected. These delays can sometimes result in delayed treatments, leading to adverse consequences for patients and anxiety. But a claim management solution streamlines the process of analyzing claims, resulting in faster payment decisions. Needless to point out, patients can avoid the stress and anxiety of slow processing.

Let’s build your project

Claims Management Software Development Services


Custom Claims Processing Software Development Services

  • Development of claim software with personalized dashboard to suit existing operations
  • Design of functions and UI/UX to ensure quality user experience
  • Features that enhance the speed and accuracy of claims adjudication
  • Optimized medical claim management to minimize claims fraud
  • A consolidated interface to exercise better control over operations and monitor workflows

Design and Development of Healthcare Claims Management Softwar

  • Compliance with the latest ICD (International Classification of Diseases) system of codes
  • Customized solutions to facilitate rapid medical claim processing
  • A wide ranging feature for EOB (Explanation of Benefits) of several medical services
  • Inclusion of process automation in the claims management solution to boost productivity
  • Feature for business intelligence to gain valuable insights into operations

Development of Healthcare Claims Management Software With Custom Features

  • Comprehensive analysis of operational requirements
  • Design of the framework for the claims management solution along with its features
  • Rigorous testing of all functions to ensure the platform’s operation and user-interface
  • Confirmation of data security and HIPAA compliance through industry standards
  • Timely deployment, coupled with training for the staff and periodic support

Our Core Services

Solutions We Offer

What Our Client Said

Industry Industry Industry Industry Industry Industry Industry Industry Industry Industry

Case Studies

Let's Begin

Latest Talks


Automated Medical Claims Processing: A Complete Guide for 2022

Read More Hear

Everything You Should Know About Healthcare Claims Adjudication Software

Read More Hear

The Best Approach to Automate Healthcare Medical Claims Management Software

Read More Hear

How Automation in Medical Billing Can Prove To Be a Game Changer for Healthcare Providers in 2022

Read More Hear

Ready to Minimize Denial and Improve Your Revenue? Customized Cloud-based Medical Billing Software is Here to Help!

Read More Hear

Frequently Asked Questions

Claims management in healthcare consists of all the procedures, processes, and protocols that insurance payers carry out in the claims workflow. It begins with receiving the claim from a provider and processing it to determine its validity. If found valid, the payer company approves it, or rejects it in case of problems. Management of claims is one of the central operations at insurance companies

The process of claims management involves the series of steps in which insurance companies verify claim requests for justification, validity, and authenticity. If everything is found to be proper, the

insurance company will reimburse the provider. If there are issues found in the claim, the insurer might withhold the payment partially or completely.

The process of claim management involves –

    1. Claim Adjudication – This involves verifying everything about the claim to determine its authenticity, compliance, and the necessity of the medical services rendered by the physician.

    2. Explanation of Benefits – Also called as remittance advice, it is the details of the insurance payer’s adjudication and contains the reasons for reimbursing or rejecting the claim.

    3. Claims Settlement – This is where the payer settles the amount that is to be paid to the provider for medical services rendered.

The purpose of claims management is to enable insurance payers to streamline the entire process of adjudicating medical claims. The workflows surrounding claims adjudication accounts for a bulk of the time, resources, and overhead for payers, and optimizing it can speed up the entire process, improve its accuracy, and also minimize the chances of insurance fraud.

Research and studies estimate that health insurance fraud costs billions of dollars every year. In light of this, a set of protocols and processes aided by dedicated software platforms can streamline claims management and optimize the whole process. This reduces the time taken for reimbursements, helps patients receive the care they need, and benefits payers in terms of greater productivity and a reduction in overhead.

Claims management is a win-win for all stakeholders involved.

A claims processing software is a digital platform to carry out the workflows associated with claims management. It digitizes all the activities involved in adjudicating claims and in doing so, improves the speed, efficiency, and productivity of the whole operation. Additionally, a software platform for claims processing would also include automation, which would eliminate the need for repetitive procedures that don’t require conscious decision-making by a human. This greatly improves the speed of the claims processing, while also minimizing errors.

Medical claim management is the set of processes by which healthcare insurance companies assess medical claims to determine their validity and the extent of coverage to be provided. It forms the major part of day-to-day operations at insurance payer companies and is also key for providers’ revenue cycles. If the claims are found to be fully valid and complaint with policies, the payer would reimburse the

provider fully. In case of discrepancies, the amount of coverage could vary. In cases of significant problems, the claims are rejected

Medical claim processing

Insurance payer companies receive claims from medical providers for the services they render to patients. The claims contain details of the services, coupled with the patients’ demographic information. These claims are evaluated by dedicated professionals who assess each claim to check its validity. This process involves verifying if the services were covered in the health plan, the importance or necessity of the medical services, and other formalities in preparing the claim. This entire process can be termed as medical claim processing.

Medical Billing

Medical billing is the process of sending healthcare claims to insurance payers for reimbursement for medical services offered. When a doctor provides medical services to a patient, the services are translated into standardized ICD codes to generate the claims. The claims are nothing but accurate summarizations of all the medical services rendered to the patient.

Medical claim processing automation is the process of automating processes and workflows associated with claims adjudication. Automation removes the need for human intervention in processes which are repetitive and don’t require conscious decision-making. In doing so, the staff involved in claim processing can focus on other important tasks and still get more work done, with few or no errors.

In short, automation in medical claim processing improves the speed, productivity, and efficiency of preparations, while lowering the overhead involved.

The following steps can improve the efficiency of medical claims management activities –

    1. Refresh patient data

Patient data is subject to changes over the course of time. Factors like age, employment, recent medical treatments, and medications matter when it comes to claims adjudication. So, it is important to ensure that patients’ data is always up-to-date.

    2. Optimize adjudication workflows

Efficiency of the adjudication process is vital for medical claims management. It is important to ensure that adjudication is done by experienced professionals and to have redundancy checks in

place. Using a dedicated software for automation is known to boost the speed and accuracy of this process significantly.

    3. Have safeguards against fraudulent claims

Fraudulent claims cost billions of dollars to the healthcare insurance industry. It is necessary to have the best safeguards against those. The latest tools include artificial intelligence and machine learning-based platforms that can detect deviations against pre-established norms and flag suspicious claims for further verification.

Efficient claims management in healthcare is vital for all the stakeholders involved. It is necessary for the payers to assess claims and reimburse providers accordingly and also avoid over-paying. For providers, good claims management ensures healthy revenue cycles due to timely reimbursements. For patients, the waiting times for important medical procedures and treatments would decrease if payers can approve of the claims faster.

Automating the healthcare claims management process requires a dedicated software solution. Payers looking for automation need to approach companies that offer software automation, or business process automation solutions.

It is important to approach a vendor that has been in business for more than a few years and has a sizable clientele. Have a look at the vendor’s portfolio of products and services, in addition to visiting an insurance payer company that uses the vendor’s products.

After selecting a vendor, you can either opt for a custom-built solution, or a pre-built one. A custom solution will be made exactly according to your needs, while a pre-built one will have a general set of features common for claims management. The former is more expensive than the latter.

In case of custom solutions, experts from the vendor company would assess your business processes and claims management workflows. This will enable them to develop a framework for an automation software to suit your needs.

Schedule A Call