As evolving regulations increase the requirement for providers to submit claims electronically, the volume of claims received on traditional CMS-1500 and UB04 forms by many health insurance and workers’ compensation carriers remains high. ActiveClaim™ automates virtually all process steps contained within a typical bill ingestion workflow in a single, ready-to-deploy solution for health insurance and workers compensation medical claims.
Unlike many processes that rely on multiple independent
systems to complete the ingestion workflow, ActiveClaim
automates the entire process by leveraging the extensive
capabilities of Kofax TotalAgility. Among ActiveClaim’s
core functions and benefits:
- Automatically verify that the patient is a policyholder and the provider is approved for payment
- Ensure claims forms are completed correctly
- Provide dynamic supervision and oversight for manual tasks
- Automate the bill return process
- Eliminate the need for costly and time-consuming custom coding and “one-off” solution development
- Deploy the solution quickly by leveraging complementary technologies from Kofax including robotic process automation (RPA) and customer communications management
- Receive real-time measurements, productivity reporting and chokepoint identification
The level of effort and associated costs to accept and adjudicate medical bills are substantial. Whether these bills are traditional CMS-1500 or UB04 (paper forms or electronic), the claims process requires several complex and costly steps:
- The processor must determine whether the individual represented on the bill has coverage and whether the bill is part of an existing claim.Many cases require the establishment of a new claim.
- Next, the processor must determine if they can pay the submitting provider. If the provider is new, many on-boarding steps must be completed before the bill can progress through the process.
- Once the validity of the claim and provider are established, the processor must extract the actual content of the bill, either automatically or as efficiently as possible by manual means. While machine-based validation can accomplish much, it can never eliminate the need for human quality assurance efforts.
- With the discovery of invalid bills — whether resulting from incomplete or invalid data, lack of coverage, or any number of other causes — comes another document-handling challenge: reducing the substantial staff hours required to inform submitters of invalid bills and manage their revised submissions.
CMS 1500 and UB-04 Claim Forms
Validated and verified claim metadata in EDI compatible 841 specifications