Home Insurance and billing workflows

Insurance and billing workflows

Eligibility and benefits, prior authorization, claims and denials.
By Swades Admin
• 4 articles

Benefit verification and eligibility checks

Benefits Verification in the sidebar. A check asks the payer, in real time, whether the patient is covered and what the patient owes. Run a check Check Eligibility → choose the payer, enter the member ID, patient name and date of birth, and the provider you are billing as. The result comes back as an outcome (Active Coverage and the rest), a Benefits Summary, and a breakdown by service type — copay, co-insurance, deductible, and what has been met so far for the calendar year. Save the provider and billing details as a template once and you will not retype them; templates also keep a bulk run consistent. Check a whole schedule Check your whole schedule runs the day's or week's appointments in one pass, so the front desk starts the morning with a list instead of a queue of phone calls. Results export for your billing team. The other three checks - Coordination of benefits (COB) — which plan is primary when a patient has more than one. - Insurance discovery — finding coverage for a patient who does not know their plan or has nothing on file. - MBI lookup — retrieving a Medicare Beneficiary Identifier from name, date of birth and social details. When a check fails Most failures are data, not coverage: - Member ID mismatch. Copy the exact member ID from the payer's own response — dashes and prefixes matter. - Name or date of birth. They must match the payer's record, not your chart's nickname. - Missing address or ZIP. Some payers require the full billing address before they will answer; the form tells you which field is missing. - Provider details. An NPI or organisation name the payer does not recognise fails every check under that template. A payer that is simply down returns an error rather than a coverage answer — retry later, and tell us if the same payer fails all day. The AI receptionist can also verify benefits before it books, if you enable it. See Booking with your EHR.

Last updated on Sep 29, 2026

Prior authorization

AI Prior Auth reads the patient's chart, drafts answers to the payer's actual portal questions, and fills the portal only after a person has approved them. It is deliberately not a one-click submitter. How a run works 1. Connect the portal. Open Prior Auth, connect the secure browser, and sign in with your own practice account on the payer portal. Your credentials are entered in the portal, never stored in HealOS. A session lasts about twenty minutes and can be disconnected at any time. 2. Load the chart. Choose New request to load the patient's chart, or Use an existing draft and give its request key. HealOS checks the chart belongs to your connected practice, and that name and date of birth on the portal match the chart. 3. Capture the real questions. HealOS reads the questions the payer form actually shows for that drug and that form — not a generic template. 4. Draft answers from evidence. Draft answers from evidence fills the answers it can support from the chart — recorded values with their dates, documented diagnoses, practice details — and cites the record behind each. Missing evidence stays unknown; it never becomes a "no". Anything narrative is matched to a quoted passage from a signed visit note, quoted exactly, or left for you. 5. Review and approve. You check every answer and its source, then approve the revision. If the form reveals new conditional questions, the approval clears and you review again. 6. Fill the portal. Fill approved answers writes the approved answers to the draft and verifies them by reloading and reading them back. The limits, stated plainly - HealOS never submits to the plan. It fills and saves the draft. Sending it is yours. - Anything ambiguous stops the run rather than guessing — an unfamiliar control, a changed question, a request in a state it does not recognise. - Treatment failure, adherence, diet-program participation and stable dosing are never inferred from records. Those are your clinical statements. - A quotation proves where text came from, not that it is clinically sufficient. Read the sources before approving. Getting it turned on Prior Auth is enabled per practice, with the payer portal and EHR combination set up with you, because each payer form has to be validated before we let it be filled. Ask support and we will tell you where your payer and EHR stand today.

Last updated on Sep 29, 2026

Submitting and tracking claims

Claims in the sidebar. HealOS submits professional, institutional and dental claims, then tracks each one to payment. Before your first claim Three things have to be in place, and the setup banner tells you which is missing: 1. An organisation. Claims belongs to a practice, not an individual — create or join one. 2. A transport profile — billing provider NPI and organisation name, submitter organisation, contact name and phone. This is who the clearinghouse sees. 3. Payer enrollment. Each payer has to accept you as a submitter. Submit enrollment starts it and the dialog shows where each payer stands. Until a payer is enrolled, claims to it will not go. Until setup is finished the screens show example data and say so. Drafts and submission Drafts holds claims in progress; the wizard asks for the claim type, patient, payer, provider, service lines and diagnoses. HealOS checks readiness before it lets you submit and names any missing field rather than failing at the payer. A submitted claim gets a confirmation and appears in tracking. Tracking Track shows every claim as a board or a table — acknowledged, in process, paid, denied, action required. Open one for the detail drawer: status history, payer messages, service lines and what the payer actually said. Some payers are slow to update; "being processed" with no movement is normal for a few days. Attachments Some payers want records with the claim. Upload the document, say where it belongs, and HealOS sends it with the claim where the payer accepts electronic attachments. Where a payer does not, it tells you instead of pretending — then the attachment goes the payer's own way. Payments Payments lists remittances with the ERA behind each one, downloadable as a PDF, plus adjustments and what landed on the patient. Follow-up surfaces claims ageing past thirty days, and the overview carries denial rate, collection rate and average days to payment. Denials have their own workflow: see Working denials.

Last updated on Sep 29, 2026

Working denials

Analyse the pattern first Upload a claims export — drop or browse your claims export on the denials screen — and HealOS reads the CSV, matches your columns, and builds the dashboards: denial rate, dollar impact, the payers and reason codes behind it, and where the money is ageing. The mapping step is worth a minute of attention. HealOS needs a claim identifier repeated on each service line, date of service, payer, charge amount, what the payer paid, and patient responsibility. It tells you which columns it matched and how many rows it skipped. CSV only, up to 15 MB. A practice usually finds the same three or four causes behind most of its denials — eligibility not checked, a missing referral or authorisation, a coding mismatch, or a timely-filing miss. Two of those are preventable before the visit, which is why benefit verification and prior auth sit next to this product. Resubmit a claim For claims submitted through HealOS, open the claim in Track and use the resubmission editor: correct the fields the payer objected to and send a corrected claim. The claim keeps its history, so you can see what changed between attempts. You can also put a claim on hold while you chase something, or mark it resolved when it is settled outside the system — both keep your dashboards honest. When you need us Send the claim number, the payer, and the denial reason code. If a whole payer is rejecting everything at once, say so in the first line — that is usually an enrollment or transport-profile problem rather than a claim problem, and it is fixed centrally.

Last updated on Sep 29, 2026