Problem Statement

Providers must be enrolled and credentialed with payers before their services can be billed, and a provider who isn't enrolled in time generates claims that deny or get written off. When a claim is held because of a provider's enrollment status, someone has to look up that provider's current standing in the credentialing system and decide what to do with the claim, resubmit it if the provider is now active, defer it if enrollment is still pending, or transfer it for further follow-up. Checking each provider's status and routing the claim by hand is repetitive, and a claim handled wrong either bills before the provider is enrolled or sits when it could have gone out.

Automation Solution

This automation looks up enrollment and credentialing details in MD-Staff and resubmits, defers, or transfers claims based on the provider's current status.