Insurance & Claims: Scheme rules, pre-authorisation, claim batching and revenue-cycle follow-up

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Billing & Cashiering

Insurance & Claims in the Bridge HMS Suite: Scheme rules, pre-authorisation, claim batching and revenue-cycle follow-up

What's inside

Everything in Insurance & Claims

46 items in 8 areas, every one shipping with the app today.

Pre-Authorization
- Pre-Auth Request RecordsDedicated pre-authorization record with an auto-numbered reference (PA/YEAR/nnnnnn sequence) for every insurer authorization request.
- Service-Type ClassificationTags each request as consultation, lab, imaging, surgery, admission, chemotherapy, dialysis, maternity or other.
- Clinical Justification CaptureMandatory free-text medical-necessity justification enforced before a pre-auth can be submitted.
- ICD-10 & Procedure CodingAttach multiple ICD-10 diagnoses and insurance procedure codes to substantiate the request.
- Supporting Document AttachmentsUpload any number of supporting files to the pre-auth via a many2many binary widget.
- Estimated Amount & CurrencyRecords an estimated cost with per-company currency and constrains it to be non-negative.
Claims Lifecycle
- Insurance Claim RecordsClaim records with an auto-numbered claim number (CLAIM/YEAR/nnnnnn) unique per company.
- Auto-Creation from BillingInvoicing a bill auto-creates a draft claim whenever the bill carries a policy and insurance amount.
- Automatic Charge PullPulls every non-canceled charge with an insurance share onto the claim and derives service date-from/to from them.
- 11-State Claim LifecycleDraft, submitted, in-review, approved, partially approved, rejected, paid, partially paid, appealed, closed and canceled with enforced transitions.
- Filing-Deadline EnforcementBlocks submission of claims past the scheme's filing-deadline window and prompts recording a past-filing rejection instead.
- Full & Partial ApprovalApprove in full or record a partial approval that must be strictly between zero and the claimed amount.
Appeals
- Claim Appeal RecordsAppeal records with an auto-numbered reference (APP/YEAR/nnnnnn), linked to the source claim.
- Appeal from RejectionLaunches an appeal wizard directly from rejected or partially-approved claims, pre-filling claim and date.
- 8-State Appeal WorkflowDraft, submitted, under review, upheld, overturned, partially overturned, final rejection and withdrawn states.
- New-Documentation AttachmentsAttach fresh supporting documents specific to the appeal submission.
- Decision Drives Claim StateUpheld reverts the claim to rejected, overturned re-approves it, partial overturn sets partially approved with a revised amount, final rejection closes it.
- Revised Approved AmountCaptures the insurer's revised approved figure and writes it back to the claim on overturn.
Batches & Submission Channels
- Claim Submission BatchesClaim batches group claims per scheme, facility and period with a BATCH/year/month/seq number.
- Six Submission ChannelsPaper form, e-mail PDF, national insurer APIs such as NHIF and SHA/SHIF, corporate API and payer portal transport options.
- Auto-Attach to BatchOn submission, claims auto-attach to (or create) a draft monthly batch when the scheme has auto-submit-batched enabled.
- Batch PDF GenerationRenders a batch cover PDF via QWeb report and stores it as an attachment on the batch.
- E-mail PDF SubmissionEmails the batch PDF to the scheme's claims-inbox address with an auto-composed cover letter.
- Batch Totals RollupStored computed claim count and total claimed/approved/paid aggregated across batch claims.
Payment Reconciliation
- Reconciliation StatementsReconciliation records (REC/YEAR/nnnnnn) capture an insurer payment statement per scheme and date.
- Statement Line ItemsLine model holding each payment reference, statement amount and matched claim/amount.
- Auto-Match EngineMatches unlinked statement lines to open claims by payment reference and scheme, capping the matched amount at approved/claimed.
- Matched vs Unmatched TotalsStored computed matched total and remaining unmatched balance against the statement's total paid.
- Post to ClaimsPosting a fully-matched statement writes matched amounts to claims, sets payment-advice ref and marks each paid.
- Post-GuardBlocks posting until every statement line is matched to a claim, and prevents canceling posted reconciliations.
Insurer API Integration
- National Insurer API Client (SHA/SHIF)A transport-safe insurer API client with configurable base URL, client ID and secret per scheme for sandbox, UAT and production.
- Pre-Auth API SubmissionPosts pre-auth payloads (member, service type, ICD-10, procedures, justification) and stores the returned insurer reference.
- Claim & Batch API SubmissionSubmits individual claims and whole batches over REST and captures the insurer's reference number.
- Retry & Timeout HandlingHTTP calls retry once on transport errors with a 30-second timeout and surface unrecoverable failures as user errors.
- Offline Simulation ModeWhen the requests library is absent, returns deterministic stub responses so offline staging and tests still succeed.
- Claim Status PollingClaim status checks and an open-claims sync refresh open claims from the insurer, auto-approving or rejecting based on the returned status.
Configuration & Catalogs
- Scheme Claim-Channel ConfigExtends insurance schemes with claim channel, API base URL, client-id/secret, API key and claims-inbox e-mail.
- Filing & TAT ParametersPer-scheme filing-deadline days, average payment turnaround days and historical approval-rate percentage.
- Pre-Auth ThresholdConfigurable monetary threshold above which pre-authorization becomes mandatory for a scheme.
- Preferred Coding SystemPer-scheme choice of ICD-10 WHO, NHIF catalog, CPT, SNOMED-CT or SHA/SHIF catalog.
- Scheme Claim CountersComputed claim and paid-claim counts per scheme with an Open Claims button.
- Procedure Code CatalogA procedure code master with code, description, category, coding system, indicative price and long description.
Cross-Module Integration
- Bill Claim LinkageAdds claim list, claim count and a pending-claim flag to hospital bills with a smart button to view claims.
- Patient Claim DashboardAdds patient-level counts of submitted, paid and pending claims plus total claimed and insurer-paid amounts with view buttons.
- Visit Pre-Auth RequirementWorks out whether a visit needs pre-authorization from scheme rules and inpatient type, with a pre-auth count and view button.
- Visit & Bill Claim NavigationContext-aware actions open claims/pre-auths pre-filled with the visit's or bill's patient, policy and facility.

Works with

What Insurance & Claims works with

Insurance & Claims shares one database with the rest of the Bridge HMS Suite and BridgeERP: these are the apps it already talks to, with nothing to buy in between.