Claims Management Workflow

Overview

The Claims Management module enables laboratories to manage the full lifecycle of insurance claims for insurance-billed orders.

The module provides a centralized workflow that allows laboratories to:

• Generate insurance claims from finalized insurance bills
• Submit claims to third-party insurance processing systems
• Track claim processing status
• Handle approvals, rejections, and partial approvals
• Resubmit rejected claims
• Maintain detailed claim history and audit logs

All claim-related data—including billing details, patient insurance information, provider details, and test-level breakdowns—is captured and stored to ensure traceability.

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Integration-Based Claim Tracking

Claim tracking behavior depends on whether the lab is integrated with an external insurance processor.

Integrated Setup

In an integrated setup:

1. Claims are submitted electronically to an insurance processor (for example, Inmediata).
2. The processor evaluates the claim.
3. The system periodically polls the processor for updates.
4. Responses are received and mapped back to the claim in LIMS.

Possible responses include:

• Claim Approved
• Claim Rejected
• Claim Partially Approved
• Additional remarks or required corrections

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Non-Integrated Setup

If no third-party processor is configured:

• Claims can still be created and tracked internally
• Manual claim management workflows can be followed
• Automated status updates will not be available

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Claims Dashboard

All claim operations are performed from the Claims List located under:

Insurance Management → Claims List

The dashboard is divided into two primary sections:

• Pending Claims
• Submitted Claims