ACO Reach Healthcare Claims Management

Automated Medical Claims Processing   Customer Relationship Management    Project Management Software   Online Dispute Resolution (ODR)    Content Management System     ERP Caretaker    Warehouse Management System    CPQ

Claims management software is required for the healthcare sector to enable compliance, provide automated and easy access to the health records and medical claims in one place. The management of healthcare claims is a highly complex process. It can be simplified by using customized medical claims processing software in conjunction with a claim integration system. Customized medical billing systems with claims integration makes it simple to access a digital archive of all records.

To take one step towards building a better medical claim processing system, Vast Edge has come up with the idea of process driven automation to analyze and integrate CCLF data. By incorporating claims management software with customized edits into the workflow system, providers can thoroughly review every line of every encounter and ensure that each claim is coded correctly and contains the correct information before the claim is invoiced and submitted for reimbursement.

EMR system's ALLSCRIPTS and EPIC were used to keep digital version of the paper charts in the clinician's office, but epic was way better than ALLSCRIPTS in handling claims and improving the speed of payments. EPIC provides interdisciplinary and patient communication within the entire team and hence make it a better option than ALLSCRIPTS.

Benefits Of Healthcare Claims Management Process

Analyze claims with greater confidence and easily identify any possible errors well in advance of claims submission.

1. Optimize
Reduce the number of claim denials, corrections, and rebilling. Improve first-time pass-through rates by optimizing reimbursement.

2. Prioritize
Execute the most efficient workflow for your team and prioritize high-impact accounts with confidence.

3. Monitor
With automatic claims status updates throughout the adjudication process, you can improve productivity and cash flow.

4. Analyze
Increase reimbursements by analyzing denials and automating the process. Investigate the root causes of denials and act quickly.

CCLF Data Integration

CCLF (Claims and Claims Line Feed) files include claims for the ACO's assigned or assignable beneficiary population. The CCLF is used to assist active Shared Savings Program ACOs with coordination of care. Claims databases collect information on millions of doctors' appointments, bills, insurance information, and other patient-provider communications. The healthcare industry has been a quick adopter of new technologies, but it's quite slow when dealing with data, data sharing, and data integration.

Data integration is still a broken process because of the problem with collaboration between healthcare providers and patients, and it has become a technical challenge in clinical data integration. ACOs (Accountable Care Organizations) usually start with the claim details in the CCLF file. It should contain all the coded financial/clinical activity for the ACO's attributed population. ACOs get month-to-month CCLF from CMS for allotted recipients, and quarterly reports, which incorporate a refreshed ACO benchmark, a rundown of credited recipients, and expenditure reports. Information and data documents are safely conveyed through a web-based entry. Given the volume of information, and the way that CMS incorporates recipient level details, the information documents can be very large and complicated. These CCLF files, provided monthly to Shared Savings Program (SSP) ACOs include Medicare claims data.

Claims Management & Approval Portal

Medical claims management means organization, billing, filing, updating and processing of medical claims related to patient diagnoses, treatments and medications. Without effective claims management in healthcare, patients wouldn't know what they owe and clinical offices wouldn't get the assets due for patient administrations.

Claims management consists of maintaining and updating patient medical histories, making changes in medical codes, as well as reporting exams and laboratory results. Claim records are also responsible for collecting, reporting and storing patient information. Medical claims management is necessary to keep track of all medical visits, treatments and expenses of multiple medical facilities and complex health insurance coverage policies.

NACHA File Generation

The ACH file format (or NACHA file) is a text file with ASCII text lines, where each line is 94 characters long and serves as a "record" to execute domestic ACH payments through the Automated Clearing House Network (NACHA). The five main record types that make up the ACH file format is header, trailer, batch header and trailer, and detailed transaction records. A NACHA file is one of the most common types of payment files and is used to execute domestic ACH payments through the National Automated Clearing House Association. It's a fast way for a business to pay vendors without having to use checks or a credit card.

Create a NACHA file using Excel:
The steps include:

  • Step 1: Identify objects and relationships
  • Step 2: Create class modules
  • Step 3: Write code to fill classes
  • Step 4: Write code to create an XML file
  • Step 5: Augment class modules until it compiles

Create a NACHA file using Vast Edge Tool for ERP:
The steps include:

  • Install the Electronic Bank Payments tool
  • Set up bank details
  • Set up an approval workflow
  • Set up your vendor records for electronic payment
    i. Set up default AP account on the vendor record
    ii. Go to Employee-> Financial-> Account Information-> Default payables account
  • Use a CSV Import to create new bank detail records
  • Generate NACHA file for vendor payments
    i. Bills are marked paid once electronic payments are approved and processed
    ii. For the "Date to be Processed" choose the next day if you are loading the file today
    iii. Make sure the vendor's default payables account is the same as the EFT bank details set up
    iv. Make sure the bill is approved if you do not see it on the list
    v. Uncheck the "Aggregate by Payee" box to create separate payment transactions
  • Start the approval workflow
    i. The approver will be emailed notification that approval is needed OR
    ii. The approver is notified of where to check for approval-This can be found in Payments-> Payment Processing-> Bill Payment Batches
  • Retrieve the file for upload to the bank
    i. Here is where to check for a processed file: Payments-> Payment Processing-> Payment File Administration
  • Upload file to your bank

Health Care Claim Payment/Advice (835) Transaction

The 835 Health Care Claim Payment/Advice provides detailed payment information about health care claims submitted to BCBSNC. The 835 Transaction may be returned for Professional and Institutional 837 Claim electronic submissions, as well as paper and electronic CMS 1500 and UB04 claims submissions. These files are used by practices, facilities, and billing companies to auto-post claim payments into their systems. The 835 Electronic Remittance Advice (ERA) provides information for the payee regarding claims in their final status, including information about the payee, the payer, the amount, and any payment identifying information.


Eliminate manual keying; save time and effort
Reduce posting errors
Increase efficiency and save money
Health Care Claim Payment and Remittance Advice, is the electronic transmission of healthcare payment/benefit information. It's mainly used by healthcare insurance plans to make payments to providers, provide Explanations of Benefits, or both. It is important to healthcare providers to help track received payments for services billed and provided.

Claims Analytics Data Warehouse

Physicians now file most or all claims through electronic data interchange (EDI), surveys show. The increased use of EDI has produced logistical efficiencies for both providers and payers, but payers have benefited most from the analytical capabilities enabled by EDI.

Patients Risk Analysis:

To prevent and minimize MSI injuries related to patient handling activities, a risk assessment must be done to determine a patient's ability to move, the need for assistance, and the most appropriate means of assistance.

There are four important areas to assess:

Assess your Patient
Assess your environment
Assess yourself and readiness to perform procedures
Assess your work organization

Providers - Medical Code Optimizations:

Medical coding is the method involved with deciphering complex clinical data, reports, and records into alphanumeric codes to later improve on the utilization of such data. By getting sorted out clinical data in such a manner, practices and clinics can further develop productivity and increment the adequacy of their tasks.

Arm your practice with qualified, experienced, and trained coders
Communicate often with your coding team
Timely attention to denied claims and accounts receivable
Capture all of the charges for the services you provide
Explore using electronic transactions

Beneficiaries Reporting:

The recipient selects a medical coverage plan and gets benefits through the strategy as paid claims as well as organization arranged rates for the part of the claim that the recipient needs to pay. The beneficiary reporting is crucial for on-going monitoring, and to get feedback on current activities. It also provides a much-needed opportunity to strengthen the links between finance and programmed staff.

If the beneficiary is involved in a liability or workers' compensation case, the doctor or other provider should send the bill if the insurance company responsible for paying primary does not pay the claim promptly, within a few months.

Medical Adherence

The medical adherence application is focused upon taking the medications correctly/timely or as prescribed by the doctor. This involves factors such as getting prescriptions filled, remembering to take medication on time, and understanding the directions.

It helps:

Control chronic conditions
Treat temporary conditions
Long-term health and well-being
It shows proactive behavior, which results in a lifestyle change by the patient, who must follow a daily regimen.

There are many reasons for non-adherence however, they fall into two covering classifications: intentional and accidental. Accidental nonadherence happens when the patient needs to follow the prescribed treatment yet is kept from doing as such by boundaries that are outside of their ability to do anything about it. Intentional non-adherence happens when the patient chooses not to follow the treatment suggestions. This is best perceived as far as the convictions and inclinations that impact the individual's impression of the treatment and their inspiration to begin and proceed with it.

We Have Saved Money For Other DCE's By

1.Implementing 4 layers of security for HIPAA compliance:
With Vast Edge, you can achieve auditable HIPAA compliance, and our data center and hosting solutions give you the peace of mind you need to comply with HIPAA regulations. We, at Vast Edge, offer 4 layers of security in HIPAA compliance to guarantee that your data is protected.

2.Checking healthcare plan expiration dates & matching against current beneficiary BAR report:
We are dedicatedly saving you enough by regularly checking on plan expiration dates and matching the beneficiary BAR report in healthcare plan.

3.Closely tracking hospice code 50 claims and average hospice days:
We closely take care of hospice code 50, i.e., tracking the patients who are discharged/transferred to hospice, also tracking average tracking days.

4.Tracking annual exams in the last 365 days & sending proactive notifications
We use proactive outbound notifications that will help prevent problems or make the patient's situation more manageable.

5.Checking for Duplicate Claims:
We use a unit of service multiplier rather than billing services on individual lines to show the appropriate unit/dosage.

6.Checking Xref MBI's:
We regularly check MBI with MBI look-up tools in cross-reference database too.

7.Generating 835 and NACHA on the day of receiving Claim reduction file:
We generate 835 and NACHA Health Care Claim Payment/Advice provides detailed payment information about health care claims.

8.Performing 3 yr CCLF historical claim analysis:
We perform CCLF historical claim analysis to assist active Shared Savings Program ACOs with coordination of care.

9.Integrating 835 with EMR systems:
EMR system's ALLSCRIPTS and EPIC were used to keep digital version of the paper charts in the clinician's office in integration with Health Care Claim Payment/Advice (835).

10.Reconciling Weekly Claim Reduction Data with Month end CCLF Part A/B claims:
We are trying to balance Weekly Claim Reduction Data with CCLF Part A/B claims at the end of the month.


1.What do we refer to as medical claim management?
The organization, billing, filing, updating, and processing of medical claims relating to patient diagnoses, treatments, and medications is what medical claims management entails.

2.What is the claims management process?
A claim management process is a system or process through which an insured person's claim for compensation for an insured loss or damage is received, processed, and verified before being authorized for compensation.

3.What is CCLF data?
Claims for the ACO's assigned or assignable beneficiary population are included in CCLF files. The CCLFs' goal is to help active Shared Savings Program ACOs with care coordination.

4.Can we simplify the complex process of healthcare claims management?
The management of healthcare claims is a highly complex process. It can be simplified by using customized medical claims processing software in conjunction with a claim integration system. Customized medical billing systems with claims integration make it simple to access a digital archive of all records.

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