Sorting rejections that need a person from ones that do not
The clearinghouse report splits into two very different piles. A rejection never entered adjudication, and most of those trace to one wrong field, an identifier that disagrees with the payer file or an invalid code for that plan, so they can be fixed and resubmitted the same day. A denial has already been judged against the plan, which means interpreting it: what the code meant this time, whether coordination of benefits is asking a question the patient has to answer, whether an appeal is worth building. Sorting mechanically between the piles and escalating every uncertain one rather than resubmitting it is what makes this safe to run without a biller reading each row first.
Electronic eligibility answers whether a patient is covered, and then somebody opens the payer portal anyway to find out what is actually payable.
There is a mandated electronic standard for eligibility, and it works. It confirms that a plan is active. What it routinely omits is the detail the front desk actually needs: frequency limitations, waiting periods, alternate benefit provisions and remaining annual maximum. That gap is the origin of most manual verification in this sector.
- Availity
- Open Dental
- Dentrix
When this is the wrong thing to build
Pick something else if your rejections cluster on one payer or one code. That is a process fix that no amount of triage replaces.
The constraint that shapes it
A practice is a covered entity, and any vendor that creates, receives, maintains or transmits protected health information on its behalf is a business associate, which requires a written agreement in place before any disclosure. More on how this sector works.
Something arrives from anywhere. It becomes one record with one owner. Read what this shape is, or start from one of these.
- Turning portal leads into one shape a person can work
- Turning an after hours maintenance call into one work order
- Entering a new client once instead of four times
- Filing client email to the matter instead of the inbox
- Booking a service call without a person typing it
- Sorting a return visit into callback or new work
- What does denial code 16 mean on a dental claim?
- Difference between a rejection and a denial in dental billing?
- How do I know whether a denial is worth appealing?
- Why did the payer deny for coordination of benefits?
- Which dental denials can be fixed and resubmitted the same day?
Back to medical and dental practices, or see how this is priced and scoped.