This workflow automatically processes billing and insurance claims for senior care services, from care documentation through claim submission and payment posting. It reduces manual billing errors and accelerates reimbursement cycles.
Care services are documented and marked complete in the resident care management system
Each node represents an automated step. Connections show how data and decisions move through the workflow.
Detailed explanation of each automated stage in the workflow.
A resident's care services (medication administration, therapy, meals, etc.) are documented as completed by staff. The system captures billable service codes and resident information.
System automatically extracts resident demographics, insurance information, service codes, dates, and provider details from the care documentation. Data is formatted for billing processing.
System checks resident's insurance coverage status and benefit eligibility for the documented services. Routes to different paths based on coverage verification results.
Automatically populates CMS-1500 or UB-04 claim forms with resident data, service codes, and provider information. Claims are formatted according to payer requirements.
System submits completed claims electronically to Medicare, Medicaid, and private insurance payers through clearinghouses. Tracks submission confirmations and claim numbers.
Automatically posts insurance payments, denials, and adjustments to resident accounts when electronic remittance advice is received. Updates accounts receivable balances.
Produces comprehensive billing reports showing claim status, payment posting, outstanding balances, and denial summaries for facility management review.
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