Software for 837 Claim Queues

ConnectiCare Solves Pending Claim Queue

A subsidiary of EmblemHealth, ConnectiCare leads the individual, Medicare and small group markets in the state of Connecticut. The company utilizes a claims management system that adequately adjudicates most claims automatically. But their system needed a way to better handle rejected 837 claim files.

“Systems that can’t easily read all EDI fields will send rejected claim files into a review or pending claim queue,” says Eric Schuyler, Director of Program Development for EMS. “The data in question is often needed for payment determinations. It can zap productivity when hours of staff time are then needed to manually review such claims.”

Schuyler shares that the software EMS created takes all the 837 claim files received by the plan and loads them into a database. It indexes those files and shows the results on a user-friendly dashboard, viewable by the ConnectiCare claims team.

By typing in a claim number or name, team members can now see all claims for the specified search criteria; select desired claims; see the raw EDI data previously missing; and send the appropriate files to the main claims management system for payment or denial.

“Our program has helped ConnectiCare to meet its ongoing productivity goals,” adds Schuyler. “It’s a case when a smaller custom software answer was the most efficient solution to a larger challenge.”

 

“It’s a case when a smaller custom software answer was the most efficient solution to a larger challenge.”