Claims Submission Agent
Validates claim completeness, scrubbing rules, and timely filing before clean claim submission to payers.
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
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.
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
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
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
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