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Claims processing for health plans and third-party administrators.

Our payer-side team reviews and processes provider claims inside your claims system. We check every claim, add the right providers to each batch, follow up on pended and held claims, and keep payments moving to providers on time.

Talk to our billing team How we work
Claims we process
  • Medical✓
  • Dental✓
  • Vision✓
  • Pended and held claims✓
  • HCSC local pricing✓
The short answer

What does outsourced claims processing cover for a payer?

On the payer side, claims processing is the work a health plan or third-party administrator (TPA) does after a provider sends a claim: checking it, deciding what the plan pays, and releasing it for payment. Claims that cannot be paid straight away are pended, or held, until someone resolves the issue.

Our team started on this side of the industry. Our first client was a Florida organization that handles billing on behalf of insurance companies, and our three payer-side claims processors still do this work every day, in clients' own claims systems and in VBA, Solstice and Guardian.

For each claim we verify patient demographics, insurance details, diagnosis and procedure codes, modifiers, provider information, billed amounts and units. We review the claim ledger to find pended or held claims and follow up on errors, rejections and denials. Where clients send batches and Group IDs for given dates, we add the right provider to each claim so the client can pay providers by service and specialty.

How we work

How we process claims.

Initial review and follow-up run on your workflow timelines, which depend on the claim type, its complexity and the documents it needs.

  1. 1
    Receive the workClaims in your system, or batches and Group IDs for given dates.
  2. 2
    Review each claimMember, coverage, codes, modifiers, provider, billed amount and units.
  3. 3
    Add providers and priceThe right provider on each claim, with pricing that follows the plan and its dependents, including HCSC local pricing.
  4. 4
    Release or pendClean claims are released for payment. Problem claims are pended with the reason recorded.
  5. 5
    Work the ledgerWe review the claim ledger for pended and held claims and follow up until each is resolved.
What is included

What payer-side processing covers.

Claim types

  • Medical claims
  • Dental claims
  • Vision claims

Processing

  • Claim review and data checks
  • Adding providers to batches and Group IDs
  • Manual pricing, including HCSC local pricing

Follow-up

  • Pended and held claims
  • Errors, rejections and denials
  • Coordination with carriers on eligibility and claim status
Systems

Claims systems our team has used

  • Client claims systems
  • VBA
  • Solstice
  • Guardian
  • NextGen Office
  • SimplePractice

Using something else? Tell us which system you use. We will say plainly whether we have worked in it before.

Patient data

We sign your Business Associate Agreement before we see any patient data.

Our parent company, Hire My Assistants KPO LLP, is HIPAA compliant.

Your BAA, signed

We sign the Business Associate Agreement your practice or plan uses, before any access is set up.

Work in your systems

We work directly in your billing or claims system, or through the VPN or virtual desktop you provide. We never download or store patient data.

A controlled floor

Restricted, monitored workstations, multi-factor login, encrypted devices, and access logs. No phones or writing material on the floor.

Checked and trained staff

Every team member passes police verification and an outside background check, and completes HIPAA training when they join the team.

Questions

What practices and plans ask us.

Which claims systems have you worked in?
Clients' own claims systems, VBA, Solstice and Guardian on the payer side, plus NextGen Office and SimplePractice on the provider side.
Which claim types do you process?
Medical, dental and vision claims.
What does "releasing a claim" mean on the payer side?
Claims that cannot be paid straight away are pended, or held. Releasing a claim means resolving the reason it was held so it can move on to payment. We review the claim ledger to find these claims and follow up on each.
How many claims can your team process a day?
Our payer-side team processes 80 to 100 claims a day. If your volume is higher, we plan the team size around it with you.
How do you check accuracy?
A team lead reviews the team's work for quality. At the start of each account we agree with you how accuracy will be measured and reported, for example by the amount paid and by the processing steps followed, so you judge us on numbers you trust.

More medical billing services

Medical Billing Services Eligibility Verification Prior Authorization Claim Submission & Rejections Denial Management & AR Follow-up Payment Posting & Recoupments Provider Credentialing Member Enrollment & Terminations
Get started

Tell us about your claims operation.

Tell us your claims system, your claim types and your daily volume. We reply within one business day.

  • We sign your Business Associate Agreement
  • US business hours, overnight or 24/7 shifts
  • $9 an hour, one rate for all billing work
Call +1 804 610 1565
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