InstaMed Connect supports professional and institutional medical claims, leveraging a standard response framework and the powerful reporting feature with InstaMed Online.
A claim is a request for payment submitted by a healthcare provider to an insurance carrier (payer) for services administered to an individual with benefit coverage from that payer.
The InstaMed claims solution includes the delivery of electronic claim billing information from providers to payers.
A remittance is the explanation of a payment for one or more claims sent by a payer to a provider. The InstaMed remittance solution includes the delivery of electronic remittance advice (ERA) from payers to providers.
Claims and remittances are electronic transactions defined under HIPAA and are assigned the transaction codes 837 and 835 respectively in the ANSI X12 standards.
- Submission is the process through which the provider creates a claim and transmits it to InstaMed.
- Delivery is the process by which InstaMed transmits the claim to the payer.
- Adjudication is the process through which the payer determines payment on the claim.
General Workflow
- The provider submits the claim using a third-party patient accounting system or InstaMed Online.
- InstaMed issues and delivers several claim responses from third parties to update the provider on the delivery status of each claim. The responses serve as an audit trail for the delivery.
- InstaMed delivers the remittance, which details the result of the payer’s adjudication process.
Validation and Adjudication
- As a claim moves through the delivery process, it may receive a status of Accepted or Rejected. Accepted means the claim will continue to process. Rejected means the processing stops and the claim does not enter adjudication.
- Claims are validated by InstaMed, the payer and an intermediary in the delivery process. All responses issued during the delivery phase are “pre-adjudication” responses.
- Both during and after the adjudication phase, the payer in some cases could issue additional claim responses called “pending” or “post-adjudication”.
- In all cases the payer issues a remittance following the adjudication, which typically indicates the claim is paid or denied. Paid means a payment is made on the claim and Denied means no payment is made due to contractual reasons with the provider or the patient’s benefits. The remittance displays full details on the outcome of the payment.
Routing
InstaMed may conduct transactions directly with the payer or via an intermediary gateway.