Problem Statement

After a claim is billed, the payer confirms receipt but staff still have to understand the payment status with the payer. To do this, staff log into each payer portal and look up each claim to see whether it is paid, pending, or denied. Then they write the status and notes back on the account. This is high-volume, repetitive lookup work. The longer an account goes without follow-up, the more likely it ages past 90 days or a timely-filing limit, putting collectible dollars at risk. Capturing statuses quickly also lets accounts receivable be segmented and routed correctly. Denials go to the right work queue, and paid claims close out instead of sitting in the follow-up pile. Pending claims can simply be left to re-check on the next run, sparing staff a portal visit until the claim resolves or stalls (3 runs or 14 business days). For UHC and UMR, claim status is available through an Optum API. Rather than navigating portal screens one claim at a time, the bot pulls status programmatically for an entire worklist at once. This is faster and scales to far higher volumes than portal automation.

Automation Solution

This automation queries UHC and UMR accounts receivable from the EMR and retrieves claim statuses via the Optum API. It crosswalks each into an actionable paid, pending, or denied status and returns the details to the EMR through a CRD and Notes file.