Claims Submission Agent

The work it takes off your plate

Dirty claims drive denials, rework, and delayed cash when demographics, coding, authorization, and attachment requirements are incomplete at bill drop. Billing teams struggle to apply payer-specific scrubbing rules and timely-filing limits across hundreds of plan variants. Manual pre-bill review is inconsistent and cannot scale with ambulatory and hospital claim volume. The Claims Submission Agent enforces completeness and scrubbing before submission so clean claim rates rise and preventable denials fall.

How it works

The Claims Submission Agent monitors claims ready for bill drop, validates demographic, clinical, coding, and authorization data against payer-specific edits, and checks timely-filing deadlines. Claims that pass scrubbing are packaged and submitted electronically; failures are returned with clear edit reasons and fix guidance. Outcomes feed continuous improvement of edit catalogs and first-pass yield metrics.

1. Step 1: Assemble Claim Packet

   • Collect encounter, coding, charges, eligibility, and authorization artifacts
   • Verify patient, subscriber, and provider identifiers against enrollment data
   • Confirm bill type, place of service, and required attachments by claim type

   Result: A complete claim package is staged for pre-submission scrubbing.

2. Step 2: Apply Scrubbing and Payer Edits

   • Run NCCI, LCD/NCD, modifier, and medical-necessity style edits where configured
   • Apply payer-specific clean-claim rules and missing-data checks
   • Validate diagnosis-procedure linkage and required revenue code combinations

   Result: Claims are scored pass/fail with actionable edit detail for any failures.

3. Step 3: Enforce Timely Filing and Submission

   • Calculate timely-filing deadlines from DOS, discharge, or denial refile dates
   • Prioritize near-deadline claims for expedited fix or submission
   • Submit clean claims via clearinghouse or direct payer connectivity

   Result: Clean claims are submitted on time with transmission acknowledgment tracked.

4. Step 4: Monitor Acknowledgments and Feedback

   • Track 999/277CA acknowledgments and early payer rejections
   • Route reject reasons back to coding, registration, or HIM workqueues
   • Update scrubbing rules based on recurring rejection patterns

   Result: First-pass yield improves continuously from submission feedback loops.

Why use it

• Raises clean claim rates by catching errors before payer submission. Protects revenue against timely-filing write-offs with deadline prioritization. Reduces denial rework volume for billing and coding teams. Standardizes payer-specific scrubbing so quality does not depend on individual biller knowledge.