Claims Management

Secure a firm foundation for revenue cycle growth.

Elevate your claims management process and decrease denials through unmatched edits and an industry-leading clean claim rate.

Claims Management Workflow
Billing Edits
Clearinghouse
Enhanced Claim Status

Flexible Claim Status

Remittance Management
Claims Analytics
Denial Management
Bill Date and Confirmation Note Posting
File Folder
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What our clients are saying.

“The SSI Group is always there to answer questions and help us create processes to meet our daily, changing needs.”

“The SSI Group is a wonderful business partner. They go above and beyond to accommodate all of our business needs.”

Claims Director, SSI’s claims management solution.

Health systems require access to technology that facilitates accurate claim submission and rapid reimbursement. Claims Director, SSI’s claims management solution, streamlines billing practices and provides visibility by guiding users through the electronic claim submission and reconciliation process from beginning to end. As payers change or modify reimbursement criteria for services, the system actively monitors and incorporates these changes and requirements. And with a comprehensive mix of edits at the industry, payer and provider levels, the solution aids organizations in making the most of reimbursement efforts.

A tool that delivers beyond the basics.

Across the industry, our depth and breadth of edits is hard to beat. Within the Claims Director solution, we provide edits for over 4,500 payers, with more than one million edit combinations available. And, at an average of over 15 years tenure, our edit team’s expertise has proven invaluable for health systems throughout the nation—for decades and counting.

Here’s a look at the types of organizations we cater to across the continuum of care:

  • Hospitals
  • Physician Offices
  • Rural Health Clinics
  • Long Term Care
  • Long Term Acute Car
  • Skilled Nursing
  • Durable Medical Equipment
  • Ambulance Billing
  • Infusion Therapy
  • Dialysis Centers
  • Reference Laboratory
  • Home Health and Hospice
  • IP and OP Rehabilitation
  • Behavioral Health

Claims Management Components

The building blocks necessary for revenue cycle success.

Our flagship solution empowers users to push claims through the system with minimal manual touches, and prevents recurring edits and denials through root cause reports.

Claims Management Workflow

Benefits

  • Monitor the entire claims processing lifecycle
  • Create smart queries and workflow queues that direct attention to the claims that require the most attention
  • Ensure claims are worked according to user-defined priority levels
  • Expedite claim correction through the use of error prompts and help messages
  • Maintain work in one system via integration features for all major patient accounting systems
How It Works

Claims processing obstacles–human error, claim rejections, improper billing and more–thwart a provider’s ability to collect in a timely and accurate fashion. A best in class, HFMA peer-reviewed solution, SSI Claims Management Workflow enables health systems to automate claim and remittance data processing, and track all data flowing into and out of the system. Instead of stressing over each step of the billing process, clients rely on the solution to help streamline activities and define priorities.

With advanced workflows, users can maximize automation and refine how claims are routed and worked. Claim and audit history functions also make it easier for health systems to track claim activity. And by integrating tightly with all major hospital information systems, clients are able to streamline and optimize staff activities.

Billing Edits

Benefits

  • Decrease denials by leveraging the tool’s leading clean claim and first time payer acceptance rates
  • Secure access to HIPAA and ANSI standard edits
  • Seamlessly request and implement custom edits
  • Gain the ability to bypass warning edits as you prefer

Pre-Billing Eligibility – SSI also offers Pre-Billing Eligibility Edits, which is a complement to front-end eligibility verification processes and does not replace or conflict with other solutions already in place.

How It Works

Maintained by a dedicated team of in-house edit experts, SSI Billing Edits allow health systems to protect against missed billing opportunities by running claims through an extensive edit suite to ensure claim compliance upon initial submission.

Edits are first initiated during the translation process, then run once again during the claims validation process to ensure previous changes do not cause additional issues to be identified. Edits are also run on claims that a user re-bills to successfully address date and time-sensitive elements. Users themselves have the ability to modify options within the system, further enabling them to improve their first-pass rate for quick and accurate payer reimbursement.

Clearinghouse

Benefits

  • Through advanced integration functions, automate the exchange of information between the system and your patient accounting software
  • Ease electronic and paper claim processing with streamlined claims workflow
  • Secure a second layer of editing to maximize first-time claim acceptance
  • Optimize staff productivity by minimizing manual work and follow-up
  • Collect claim payments from payers with greater ease and accuracy
How It Works

Successful revenue cycle management begins with EDI workflow. With over 900 direct payer connections and more than 100,000 discrete edits, it’s not surprising that one-third of the U.S. health system market relies on as the SSI EDI Clearinghouse to handle their claim submission and processing. Organizations can submit HIPAA transactions in real-time or batch to commercial and government payers, including Medicare and Medicaid; check eligibility and benefits (270/271), file medical claims (837P and I), receive electronic remittance (835),  and review claim status (276/277), and submit authorizations and referrals (278). 

Clients rely on the solution’s integration capabilities to automate the exchange of information between the clearinghouse and their health information system, minimizing manual labor requirements for their revenue cycle teams and allowing for quicker, more accurate payer collections.

ERA payer connections, coordinates payer registration on behalf of the provider, and works with payers for remit file issues. With a streamlined remittance process, providers are able to see payments applied to an invoice or claim, and explore the reasons for denied or partial payments.

Our nationally recognized clearinghouse provides connectivity to payers for electronic remittance retrieval. Once a file is available, the clearinghouse will automatically retrieve it and place the file in a common directory allowing for posting to the host and/or accounts receivable system.

Flexible Claim Status

Even in today’s world of electronic transactions and real-time information availability, health systems routinely rely on manual claim status processes. According to the CAQH Index ® report, in 2021 providers made 168 million claim status inquiries by phone, fax or e-mail, each of which takes 25 minutes per transaction and costs the industry over $283,900,000 annually.

The ability to check a claim’s status is an essential element in the claim lifecycle, but each payer’s process is unique. Using the best available Claims Status Option for each payer can dramatically reduce the provider’s time to payment. Technology solutions can help—and SSI offers several options for the claim status process. Here are benefits to using the best Claims Status Option for each payer:

  • Identify denials before receipt of the remittance advice
    • Rebill claims that are correctable
    • Start the appeals process sooner for claims that need it
  • Decrease payment turnaround by responding to requests for additional information sooner
  • Increase staff productivity by using exception-based workflow, so that users can focus on just the claims requiring attention and follow-up, increasing staff productivity
  • Increase efficiency with payer specific settings allow for status checks to be driven based on payer behavior
Claim Status Module for Medicare DDE
  • Import of claims from the Billing Module
  • Automatic statusing of Medicare Part A claims in the Medicare Common Working File (CWF)
    • System options allow for status timing and other settings
  • Ability to work claims requiring follow-up in Billing, Claim Status Module, Medicare CWF, or Host system
    • Claims worked in the Claim Status Module are updated real-time in the Medicare CWF
  • Note posting files are available for updating the Host system
  • Can be used with any Host system in place
Claim Status Module for EDI
  • Import of claims from the Billing Module
  • Automatic statusing of Commercial & non-Medicare Part A claims for payers using the standard ANSI 276 claim status request and 277 claim status response transactions
    • System options allow for status timing and other settings
  • Ability to work claims requiring follow-up in Billing, Claim Status Module, or Host system
  • Note posting files are available for updating the Host system
  • Can be used with any Host system in place except Epic
Payer Status Query
  • Counterpart to Epic’s Payer Status Query capability
  • Bidirectional interface between Epic and the SSI Clearinghouse
    • Epic initiates the standard ANSI 276 transaction based on workflow within Epic or on-demand from Epic
    • The SSI Clearinghouse responds with a standard ANSI 277 claim status response
    • The claim status response will automatically drive any workflow set-up within Epic
  • Uses CAQH’s CORE web service for a real time transaction with a guaranteed response time of 20 seconds or less
  • Only for payers supporting the standard ANSI 276/277 transactions
  • Currently only for sites with Epic as their Host system
Enhanced Claim Status
  • Import of claims from the Billing Module
  • Automatic statusing of Commercial & non-Medicare Part A claims using Robotic Process Automation (RPA) or Application Programming Interfaces (APIs). For use with:
    • Payers that do not use the standard ANSI 276/277 transactions
    • Payers who provide more content on their web portals and/or faster return of data than in the 276/277 transactions
    • Payers who offer enhanced claim status API’s containing more content than the standard 276/277, RPA is the method of last resort
  • Ability to work claims requiring follow-up in Billing, Claim Status Module, or Host system
  • Note posting files are available for updating the Host system
  • Image files captured from payer web portals & APIs are available for upload in the Host system
  • Can be used with any Host system in place

Remittance Management

Benefits

  • Ease billing to payers subsequent to the primary payer on a claim
  • Access, view, and print Explanation of Benefits (EOB)
  • Establish a single source for all electronic payer remittances available
  • Post files to host and/or accounts receivable systems
  • Guide staff activities with system-initiated denial follow-up
How It Works

More effectively manage cash flow while keeping up with the various payment types within the industry. SSI Remittance Management manages the retrieval of remittance files and processes an 835 from any payer’s file, allowing providers to electronically auto-post payments. The application manages ERA payer connections, coordinates payer registration on behalf of the provider, and works with payers for remit file issues. With a streamlined remittance process, providers are able to see payments applied to an invoice or claim, and explore the reasons for denied or partial payments.

Our nationally recognized clearinghouse provides connectivity to payers for electronic remittance retrieval. Once a file is available, the clearinghouse will automatically retrieve it and place the file in a common directory allowing for posting to the host and/or accounts receivable system. 

Denial Management

Benefits

  • Easily categorize and establish root cause assignment on denials
  • Develop streamlined claim and line-level denial workflow
  • Establish a method to manually link remits to claims not matched initially
  • Auto-assign denials to users based on denial type
  • Incorporate follow-up and timely appeal filing deadlines into workflow
How It Works

Minimize the volume and burden of denied claims. SSI Denial Management allows users to identify and monitor the impact of denied claims, view denial trends, manage denials, and determine root cause by accessing the most granular claim and remit data.

Custom work queues automate and simplify the follow-up process and allow staff to easily organize, prioritize and manage underpayments and denials. With powerful reporting capabilities and activities based on user or role, organizations can appropriately divide work based on staff experience and expertise, and track custom key performance indicators (KPIs) to determine the success of their efforts to increase net revenue.

Bill Date and Confirmation Note Posting

Benefits

  • Maximize your investment in technology through seamless integration between the claims management tool and your hospital information system
  • Receive guidance for appropriate follow-up and workflow in your host system
  • Automate processes based on bill job completion and/or confirmation and claim status receipt
How It Works

The Bill Date Note posting file is created when a bill job is generated, usually on a scheduled basis. Confirmation Note posting files are created upon receipt of Confirmation Reports and/or claim status files from the clearinghouse.

The information in the Bill Date and Confirmation Note files can be posted as a note or comment in the host system or mapped to specific host system fields. These notes allow for timely and accurate information to be available for inquiries and/or follow-up. When posted to specific fields in the host system, workflows and/or follow-up set in the host system can be initiated.

File Folder

Benefits

  • Acquire a repository for all pertinent documents created during the claims management lifecycle
  • Access the feature from any claim in the system
How It Works

Maintain compliance with data retention requirements and seamlessly gain access to information necessary for billing and appealing claims. File Folder is a document management and storage function available in, and specifically linked to, claims in the Claims Management system. Documents such as claim images and remittance information can be automatically uploaded within the system. Information on a given claim is accessible from the File Folder icon and will only display details and documents associated with that claim.

File Folder can be used to store images and documentation gathered during patient registration, at the time of service and any time after services are completed.

Additional Functionality

Correspondence Conversion
Extract index data from scanned images of paper-based correspondence letters typically received from payers, which can be archived and fully searchable by indexes.
EOB Conversion
Extract data from scanned images or PDF documents created from paper-based Explanation of Benefits (EOB) or Explanation of Payments (EOP) to deliver an EDI 835 Electronic Remittance Advice (ERA) files that are ready for cash posting in practice management or hospital information systems.
Electronic Attachments

Alleviate administrative burdens with an integrated, multi-channel system that allows users to send electronic attachments to payers for claims requiring additional documentation.

Pre-Billing Eligibility
Reduce denials and unnecessary write-offs by determining coordination of benefit discrepancies before the claim is billed.