What’s a typical CMS-1500 workflow, and how does ClaimsCapture fit into it?

The CMS-1500 is relatively rare for some firms but ubiquitous for others (such as niche Medigap claims processors or public health agencies). Workflows usually result in EDI 837 output, but steps and details vary widely.

The common thread is reliance on manual effort for steps that today’s software can accomplish more efficiently, and that is where ClaimsCapture enters the picture.

Please refer to this CMS-1500 workflow overview for a much closer look at CMS-1500 processing and how this tool addresses some inherent challenges. We’ve also summarized some common use cases from recent real-life deployments.

What can ClaimsCapture do out of the box?

Out of the box, it automates the repetitive and error-prone work that makes manual data entry so painful. It comes equipped to pull in scanned CMS-1500 / HCFA-1500, CMS-1450 / UB-04, and ADA J430D forms; extract and intensively validate their data; and export the results in several common database, flat-file, and EDI-friendly formats. It does all the above in accordance with your unique business rules.

A lot of our incoming CMS claims have multiple pages. Others are duplicated. Do those cause problems with the software?

We’ve built in robust features to handle multi-page documents and identify duplicates with ease. As most customers know all too well, these are especially slow and tedious tasks to perform by hand. They also tend to cause errors that lead to costly outcomes like denials and underpayment. The time savings with ClaimsCapture are significant and immediate for complex and/or duplicated documents.

How about handling cases where the patient isn’t a member of the plan?

Absolutely! ClaimsCapture can flag claims pertaining to non-members before creating and submitting an EDI data set, thereby avoiding a PDR (provider dispute resolution) request in the first place. That is one of the main reasons why it contains so much validation and cross-reference logic! After all, capturing data correctly is a great start, but making it useful requires nuanced business and medical context, like plan membership or code validity.

What does it take to get up and running?

ClaimsCapture already includes everything needed for end-to-end automation of scanned claims forms. Set-up entails little more than installing on your servers/desktop, pointing it at the right folders, and connecting to your organization’s security model.

How long does it take to implement ClaimsCapture?

In most cases, ClaimsCapture only requires two to three days to implement. The timeframe is short because we’ve incorporated years’ worth of client feedback and observations, which translates to hundreds of pre-built features—easily turned on or off—that accommodate business needs right off the shelf.

Can you customize it for our organization?

Absolutely. The same team that built ClaimsCapture can also customize it to incorporate additional form types, integrate with virtually any document source or business application, and follow any business logic that you can describe.

Naturally, customization is always available upon request. Some clients find it highly time- and cost-effective to complete all customization before the initial go-live. Others prefer to begin with a pilot project and add changes gradually. The latter approach works especially well when stakeholders need to see early “wins” with minimal investment.

I like the idea, but how much automation should I really expect after implementing ClaimsCapture?

The quick answer is: it depends on the quality of the document. All of our clients realize a high degree of automation by implementing ClaimsCapture. They often eliminate over 90% of the data entry, document handling, paper storage, and other inefficiencies.

We receive a lot of copies or black-and-white scans of claims, and other OCR tools have a hard time reading them. Does ClaimsCapture support B&W photo- or fax copies?

Yes, ClaimsCapture processes black-and-white claims extremely well—almost as well as the original (red) forms, in fact. On some forms, the challenge is that the data touches the field label, which makes it extremely hard for most software to differentiate the form itself from the data to extract. ClaimsCapture has multiple sophisticated algorithms that are highly effective at distinguishing the red originals from B&W copies, and accurately processing the latter (even from faxes and low-resolution scans!).

Does it only export claims forms to certain back-end databases or systems? 

ClaimsCapture exports data from scanned CMS/HCFA/UB/ADA forms to any ODBC-compliant database plus several flat-file formats such as CSV, Excel, and EDI 837-friendly XML. Additional, custom export format may also be possible, but we’ve found that the standard options cover virtually all common business systems/repositories. 

We also handle dental claims. Does ClaimsCapture work with ADA claims forms?

ADA claims forms like the J430D are a common and growing use case for ClaimsCapture. It handles scanned ADA claims forms just as accurately as the CMS-1500 and CMS-1450, and offers all the same workflow and business logic extensibility.

Can it export scanned CMS-1500 forms as an EDI 837 file to our adjudication software?

Yes, it can export an EDI 837 file with all of the data points that were captured from the claim form. ClaimsCapture’s advanced EDI integration allows clients to quickly ingest the data.

Does your software have a way to validate certain CPT codes?  

Yes, it identifies CPT codes within a CMS-1500 form and can run them through various validation steps. CPT code errors—whether from typos or outright coding mistakes—are one of the major sources of claims processing delays. Automated validation has been a top priority and an out-of-the-box feature since day one. The same applies to ICD-10 codes, too! 

Which document management systems does ClaimsCapture integrate with?

It works with almost every document management system, including SharePoint, OnBase, and many other major and niche solutions. We’ve built it with a flexible approach that exports data and images in many different formats that a DMS can understand.

Can it automatically name the exported files, and the folders to which the claims are exported?

Yes, ClaimsCapture has advanced taxonomy capabilities that can use any claim form data to create folders, sub-folders, and file names automatically.

In addition to capturing the data, we have different processing rules based on the content of the claim. Can your software fit into specific processing workflows?  

If you can articulate the business rules, then ClaimsCapture can obey them. In many cases, its AI capabilities render it more accurate (and, obviously, faster) than a human processor.

Furthermore, ClaimsCapture also includes the ability to perform certain claims workflow steps by itself, rather than routing to another tool. Some of the more universal actions are built in, and customization possibilities are just about infinite.

What are the deployment options? Is it outsourced?

We deploy ClaimsCapture on-premises, in your private cloud, in a secure public cloud (e.g., on an Amazon Web Services / AWS, Azure, or Google virtual machine), or as a managed service. Whatever your business and technical deployment goals, ClaimsCapture can fit the bill.

How much does ClaimsCapture cost?

The pricing model is primarily usage-based, so it depends on the number of claims that you process each year. If the data entry process is fully manual today, then you can anticipate a cost reduction of 80%-90%. That typically brings a return on investment in less than 6 months, and in almost every case, the ROI timeframe is 12 months or less.

How do we get started?

Give us a call! We’ll chat about your needs to confirm that ClaimsCapture really is a good fit, then walk through the systems and people that will make it a success.