Medical Claim Management


Payers experience challenges with managing manual workflows and claim pends in their adjudication system. This slows down their ability to pay claims quickly and accurately. It also means they are relying on their adjudication system to manage critical workflow components such as matching, editing, reject handling, and more.

Smart Data helps solve these challenges by ensuring we automate workflows up-stream so we can drive quality claims data to the front door and increase auto-adjudication rates. This allows you to maximize the capabilities of your adjudication system and let SDS be your front-end data quality partner to feed good data to that system.

Below are examples and detailed descriptions of claims management automation:

  • Clinical Editing
  • Provider Data Base Clean-Up
  • Duplicate Checking
  • Extensive Reporting Capabilities
  • Double Key Reconciliation
  • Pre-Adjudication Edits
  • Mandatory Insurer Reporting (MIR)
  • Provider File Matching
  • Eligibility Matching
  • Submitter and End User Services
  • 5010 In-Site
  • Eligibility and Claim Form Return
  • Medicare MedSup Cross Connect
  • Portals

Automated Member & Provider Matching

Once we have a clean 837, SDS’ core objective is to ensure that SDS-sourced claim results in reduced labor and improved auto-adjudication.

Automating the member and provider match is a critical component of claims processing. MemberMatch is our automated member match tool that utilizes a blend of proprietary and public domain algorithms that automate eligibility matching. Specifically, we utilize weighted combinations of these algorithms to identify the correct match.

SmartMatch is our proprietary automated provider matching utility. SmartMatch uses a weighted combination of proprietary and public domain string comparison algorithms. Its modular design and process of elimination approach enable very high match rates. Nearly all SDS clients use this to improve payment accuracy while reducing cost and turn-around time.

Implementations usually include some degree of customization to accommodate client-specific matching rules.

Automated Claims Routing

Smart Data can also automate your EDI routing to your trading partners. Whether it’s a repricing network or clinical editing partner, we can automate the route so you receive cleaner and more accurate data once it hits your adjudication system.

Clinical Editing

Smart Data can automate route to your clinical editing partners.

Image Archiving

Part of managing the claims process is ensuring original paper claim images and other data is archived for users to access. SDS offers a proprietary (SafeClaim) archiving tool where materials are stored for 10 years. The data is hosted out of 2 tier 4 co-location facilities with 24X7 security, dedicated power supply, and backup generators on-site. With Smart Data Solutions image archive and retrieval system claim images are available for retrieval within fifteen minutes of scanning the batch. After the capture phase, the claims can be retrieved based on any data captured off the claim and retrieval screens are typically customized for each client.

SafeClaim store all claim related materials such as:

  • Paper claim image
  • Non-claim correspondence and indexed information
  • Data captured
  • EDI

Rejected Claim Process

Rejected claims and claims requiring modification are unavoidable in the process. The reject handling is extremely time consuming and introduces process delays. Since our goal is to only send payers good clean data ready to auto-adjudicate, we provide work queues to help streamline the rejected claims process. All reject conditions are fully customizable within our system.

We start by pending rejected claims to a Smart Data work queue to ensure it wasn’t a capture error. If it was we’ll correct it and get it back into the workflow so you receive clean 837’s. If it wasn’t a capture error, it will be sent to a pended reject queue for the clients analysts to access and make a correction if able. The claim then goes back into the workflow. This allows the client to have control and transparency throughout the process, and avoids unnecessarily rejecting claims.

Provider File Clean-up

Maintaining a clean and up to date provider file is challenging for many payers. Provider files contain duplicates, non-standard addresses, formatting issues, and other headaches. The challenges lead to lower auto-adjudication rates, increased provider match pends, increased 1099 forms, and inaccurate payments.

Smart Data can help by detecting duplicates and eradicating them, augment provider records, format the data per your adjudication system, and help with ongoing maintenance by automating provider match and support new provider additions.

Medicare (MedSup) Cross Connect

For clients that offer Medicare supplemental plans, Smart Data can help manage the CMS connection for you. We coordinate the E01 eligibility file and manage the testing with CMS / GHI, as well as create your COBA ID to receive the claims. Additionally, if we’re performing paper conversion to EDI, we can receive the claims with EOB attachments and run duplicate check on the ICN to ensure we tease out duplicates that you’ve already paid.