Health Insurance Clearinghouse workflow and understanding

I need to create a very detailed report that will answer the following questions. It is very important to identify all the major payors and to understand how a provider can verify and authorize through the EHR versus a standalone system. For example is the process to verify insurance with BCBS of TX different than BCBS of TN

Document the process flow for a patient calling or visiting an office and having the insurance verification and authorization done prior to the visit.
- Also understand if it is possible for the patient to understand what their bill will be upon checkout based on the verified and authorized benefits.
- A practice will populate the insurance/verification screens within existing ehr (or Soteria) and connect to the identified payor to verify and/or authorize the copay, payment, or procedure payment within the same system. (dont want to leave the existing system)
- Understand the information that is available through the payor to populate the insurance and verification screens in the Soteria (or existing system)
- Communicate and confirm to Soteria the data available in order for developers to create screens to capture the data.
- How to connect through HL7 (version being used) or HL7 FHIR, Json or what other means
- Are the various payors using different versions of HL7 or other connectivity
- Do the same payors use different systems, versions, connections? For example does UnitedHealth TN use a different System than United Health TX. If connected to one are we connected to all the systems?
- Is each payor in each state its own company and therefore use different systems? For example maybe United Health is the same across the US, but BCBS is different
- Is there a cost to connect to the payor system or will the payor pay to get connected
- Understand what an office needs to do to authorize a procedure. What is the workflow and is it the same in all offices? It is understood that a message is sent from a task list in order to get the procedure complete
- Are there any third party systems available that only do validation and authorization without selling a complete system?
About the recuiter
Member since Nov 11, 2022
Mughaffir Yunus
from Sind, Pakistan

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