2260 Apollo Way, Suite 103
Santa Rosa, CA  95407
Phone: (800) 763-8484

Claim Scrubbing

ClaimRemedi actually scrubs claims much like the payer back-end processing systems — except we do it up front, at the time claim submission. We not only check your claims for documented payer rules, but also “undocumented” rules that we encounter by “reverse engineering” actual payer rejections and denials.

You can say, “goodbye” to claims that are repeatedly submitted and denied. Just imagine the benefit to your organization of using this predictive technology to correct claims before initial submission.

Payer rules are stored in a comprehensive rules engine that is maintained and updated weekly — using payer bulletins, code releases, and by reverse engineering payer rejections and denials.

Rules are payer specific. Rules that apply only to Medicare are applied only to Medicare claims. Rules that apply only to a specific commercial payer are applied only to that payer. Rules are date sensitive. For example, valid procedure and diagnosis coding is by date of service.

Rules can be quickly added or changed — without programming. If you feel that you need a rule that we don’t have, we can quickly add it to meet your specific needs.

Rule categories cover both professional and institutional claims:

  • Procedure coding is checked for gender and age restrictions, inclusion of any required accompanying procedures, appropriate use of modifiers and proper place of service codes. CCI policy compliance and medical necessity using CPT/ICD9 crosswalk data and LCDs/NCDs can also be incorporated.
  • Diagnosis coding is checked for use of valid primary diagnoses, proper levels of specificity, gender and age restrictions, and the inclusion and ordering of any required accompanying diagnoses.
  • All UB-04 specific codes — ICD9 procedure codes, DRGs, revenue codes, patient status, type of visit, condition, occurrence, treatment and value codes — are checked to see that they are correctly reported when required.
  • Situational/conditional fields are checked to see if they are required and reported. Some professional claim examples — the reported diagnosis requires an accident code, accident date, date of first symptom; referring provider required because referral number is reported; date last seen required for this specialty; etc. Some institutional claim examples — the reported diagnosis requires an occurrence code; the reported revenue code requires a value code, a procedure code or covered days; date of service or patient status code required for this type of bill; etc.