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    4. 4 HEALTHCARE IS A BUSINESS What comes in must equal or exceed what goes out Compression is an issue. Increases in costs must be met by increases in revenue, and/or decreases in revenue must be met by decreases in costs. Claims processing is the circulatory system of healthcare.

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    6. 6 COMMON SENSE Many industries have demonstrated that following industry standards can create great efficiencies. HIPAA took valuable first steps to standardize claims processing in healthcare. Payers, however, applied their own interpretations to the guidelines, leaving the industry still fragmented.

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    11. 11 OPPORTUNITIES Efficiencies can still be accomplished by combining refined standards with valuable electronic processes. “Little things” make a Big difference. Funds saved in one area can be used in others.

    12. 12 CLAIMS PROCESSING FLOW

    13. 13 Claims Processing Key Payer/Provider Contract*and 1+ Credentialing* Patient Contract Patient Eligibility* Co Pay Patient Balance Owing Plan Claim Submitted* & Claim Received* Claim Status Update* Payment- Paper/Electronic* EOB/ERA- Paper/Electronic* Reconcile Submitted Claim to Paid Claim** Reconcile Payment to Claims** Match Payment to Contract** Deposit to Bank Posting to Accounting System Billing and Collecting Balance** Filing / Archiving/Retrieving ** Patient Billing and Collection (15) Patient Co pays and Balances Deposited Patient Co pays and Balances Posted

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    24. 24 UHIN Standardize and Apply (Tools)

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    32. 32 Click On $340.80 in the Associated Amount Column to View the Claims That Were Settled by ACH4665294. Click on the “Trans Image” icon will open an image of the patient’s check. The Transaction Numbers are Listed with the PP Prefix Identifying them as “Private Pay” Transactions. Clicking on the Transaction Number Will Open a Display of the Transaction Data from the NetDeposit Transaction Clicking on the Transaction Number of a PTCC (Credit Card Payment) Will Open a Display of the Transaction Data from the Credit Card Transaction Click On $340.80 in the Associated Amount Column to View the Claims That Were Settled by ACH4665294. Click on the “Trans Image” icon will open an image of the patient’s check. The Transaction Numbers are Listed with the PP Prefix Identifying them as “Private Pay” Transactions. Clicking on the Transaction Number Will Open a Display of the Transaction Data from the NetDeposit Transaction Clicking on the Transaction Number of a PTCC (Credit Card Payment) Will Open a Display of the Transaction Data from the Credit Card Transaction

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    38. 38 CLAIMS PROCESSING FLOW

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