Insurance verification and claims processing

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

1. 1

   Trigger

   Appointment scheduled in system

   Patient books an eye exam appointment through the practice management system. This triggers the insurance verification workflow to begin automatically.

   EyefityPractice ManagementCompulink Advantage SMART Practice
2. 2

   Action

   Extract patient insurance information

   System retrieves patient's insurance details including member ID, group number, and policy information from the patient record. Missing information triggers patient notification for updates.

   EyefityPractice ManagementMaximEyes
3. 3

   Action

   Verify eligibility with VSP

   Automated API call to VSP Vision Care validates patient's current coverage, benefits, copay amounts, and authorization requirements. Real-time eligibility status is retrieved and recorded.

   VSP Vision CareRevolutionEHR
4. 4

   Decision

   Check coverage status validation

   System evaluates if insurance is active and covers requested services. Workflow branches based on coverage approval or denial status.

   VSP Vision CareWinOMS
5. 5

   Action

   Generate pre-authorization if required

   For covered services requiring prior authorization, system automatically submits pre-auth requests with patient and procedure details. Authorization status is tracked and updated.

   VSP Vision CareCompulink Advantage SMART Practice
6. 6

   Action

   Create and submit claims

   After exam completion, system automatically generates insurance claims with proper CPT codes, submits electronically to VSP, and tracks claim status. Rejected claims are flagged for review.

   VSP Vision CareRevolutionEHRWinOMS
7. 7

   Output

   Update patient financial records

   Final step updates patient account with verified coverage details, processed claims status, and outstanding balances. Staff receives notification of any required follow-up actions.

   MaximEyesEyefityPractice Management

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