HealthLink’s front-end vendor scans paper professional claims and institutional claims when the claim meets scanning requirements. The vendor uses optical character recognition (OCR) to interpret the characters and automatically populate the data elements into the proper fields for verification and subsequent transmission of claims electronically to HealthLink’s claim repricing system.

The scanning process removes the red color on the HCFA-1500/CMS-1500 and UB-92/UB-04 and displays the characters to be interpreted by the OCR engine. In the event the document cannot be read with 100% accuracy, human intervention is employed to correct and “data-enter” any fields that are unclear or questionable. A verification step is used for both reviewing and correcting specific data elements. During the verification step, snippets of each image can be enlarged and are available for the verification operator to make the needed changes.

Quality control steps are in place, and designed to identify wrong characters using logical and database validation steps. Some fields, for example, can only be valid if numeric and certain character length. Zip codes may not have dashes. Date fields must contain eight numbers in “mmddyyyy” format. Zip codes are validated for a certain state.

Procedure codes, diagnoses and other codes are validated by the front-end vendor using a database of valid codes. Logical validations include verification steps such as checking that the “to date” cannot be earlier than the “from date”. Total billed charges are added on each claim and checked against the total billed charges field on the claim form. Provider TINs are double-checked by reviewing options in a provider database.

These validation steps were created to enhance repricing accuracy.

During the transition period for the new, national paper (manual) claim types, the front-end vendor will accept and scan both versions, creating an EDI 837-4010A1 claim for Healthlink’s/NCPPO’s repricing.

Provider education steps have been taken to ensure a high percentage of paper claims are received with the correct, red background color; as well as education to improve our inbound electronic claim submission rate, in lieu of submitting paper claims. Claims from providers without valid subscriber and patient identifiers or without valid diagnosis and procedure codes are returned to the provider for correction and resubmission.

In the event a scanned/OCR claim cannot “pass” the edits to produce a complete claim, HealthLink creates manual claims and repricing sheets for manual handling by the payors.

Scanning claims and using OCR technology create reliable claim images and result in translating paper claims into outbound electronic claims with repricing segments.

Scanning and OCR technology are utilized to increase the electronic claim incidence, reduce expenses associated with manual handling, and ensure the “best in class” for PPO repricing turnaround time.