Revenue cycle
Eligibility and remittance, straight from the payer.
The transactions have standards: 270/271 for eligibility, 835 for remittance. The problem is access: getting them means a clearinghouse, an EDI envelope, and a per-payer enrolment that takes weeks. Or it means a person with a browser.
A browser tab per payer, all morning
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Sign in to the payer portal
Often a separate credential per payer, frequently with MFA, and sometimes with a separate login per provider group or TIN.
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Run eligibility for today’s schedule
Patient, member ID, date of service, submit, read the response. For a full clinic list, that is the same form dozens of times.
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Download remittance advice
Find the ERAs posted since the last check, download them, get them into the practice management system. Repeat per payer.
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Chase the denials
Read the adjustment codes, work out which claims need a corrected claim or an appeal.
The payer portal becomes a queryable source
- Batch eligibility checks: submit the day’s patient list to each payer and collect responses before the first appointment.
- ERA retrieval on a schedule, per payer, without anyone remembering to look.
- Denial and adjustment capture: pull the codes that explain why a claim paid short.
- Claim status polling for the claims that have been sitting in limbo.
- Structured output delivered by webhook into your revenue cycle tooling.
This is not a substitute for a clearinghouse where one exists. It is what you use for the payers that never enrolled.
Where this fits, and where it does not
Use it for the long tail of payers
If a payer supports EDI through your clearinghouse, keep using it. It is cheaper and more reliable. The gap this fills is the payers that either have no EDI relationship with you, or charge per transaction for one.
PHI changes the deployment conversation
Eligibility responses and remittance advice contain protected health information. For anything involving PHI, assume you want the Enterprise deployment: the runtime inside your own cloud, the master key in your KMS, and a signed BAA in place before any real data moves. We will not process PHI in a shared environment.
Read-only is almost the whole value
Eligibility checks and ERA downloads are read-only and deliver nearly all the benefit. Claim submission is a different risk category entirely, and we recommend it only after the read path has run cleanly for a period.
The honest failure mode
Payer portals rate-limit aggressively and sometimes present CAPTCHA after a burst of queries. Runs should be paced, and a portal that CAPTCHAs on every few submissions is a poor fit for batch eligibility.
Start with the payer you cannot get an EDI feed for.
Read-only, in your own cloud, with a BAA in place.