Healthcare Claims Processing

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Our Claims Processing division is responsible for secure and accurate data entry of forms such as HCFA 1500, UB-92, ADA and EOMB (Explanation of Medical Benefit) on a daily basis. Each of these forms range from a one page document to several pages and have certain key fields, which are important for a claim processing company and need to be keyed.

The process involves scanning/imaging these documents or accepting them from our clients via ftp. Critical data is extracted using OCR technology or a “Manual double key & verify process”. The use of our Key From Image (KFI) technology allows us to route non-readable forms (where OCR is not a viable option) to this system where we populate predefined fields using the double key process for maximum accuracy. We log in directly to our client’s proprietary application using a secure log in. Alternately the output data is formatted in an electronic file, which is transmitted to our clients in an ASCII comma delimited, flat ASCII, HIPAA 837 X12, 835_4010 or NSF format (or any other format they might require) for processing.

We can process individual HCFA and institutional UB92 claims as well as dental claims.

We offer to take responsibility of the entire process. Starting in the mailroom, the claims get opened, removed from their envelopes and sorted into separate piles: single sheet claims, multiple sheet claims, HCFA's, UB92's, Dental Claims, and miscellaneous other sheets which cannot be processed. Document preparation includes removal of staples, paper clips, photocopying documents on colored paper (for maximum contrast) and generating batches. The forms are then scanned at 200-300 dpi depending on the quality of the forms. While scanning we use a red filter located in the scanner to remove the form. As a result, our images are approximately 15kb or so each. We use our extensive imaging experience to ensure that the resulting image files are optimal for the OCR or Key From Image portion of the process.

Predefined fields are OCR'd and validated for field content. If acceptable, a control number is assigned. Critical to our process are two exception handlers. This exception handler allows the system to determine if the claims are good enough to OCR (any claims that do not meet validation rules or that do not OCR at more than 80% accuracy go to this exception) if they are not the claims is re-routed to our exception program where the claims will be Keyed From Image.

Why 80%? Well we found that it is more effective for an operator to key all the data if more than 20% needs to be corrected. If there is more than one character wrong in a field it is quicker for our operators to re-key the whole field than try to fix it. Statistically, a more than 20% error rate means that most fields will contain more than one error.

Once the forms are scanned and OCR'd successfully they get assigned a control number and an image number, which is indexed in the output file associated with that claim. The images get stored on our File Server for client access and download. The rejected pages are either re-scanned as images or re-routed to our exception key entry operators. While this is going on, our data entry stations are looking for batches of images that need to be corrected or key entered. The batch is opened on a verification station creating a split screen displaying the image on the right and the zoomed in zone on the left and key entry fields below with any unreadable characters displayed by highlighting it in yellow.

Once the batch is complete, and the image record is flagged as keyed, the automated job-flow process sends the batch through the output queue into a text file holding the job in an ASCII comma delimited format.