Alpha II Claimstaker Clinical Claim Scrubber


Clean Claims. Accurate Reimbursements.

Claim editor or "claim scrubber" software is rapidly becoming an industry-standard feature of medical billing software. But only one claim editing application verifies both professional and institutional claims from the payer's perspective using the industry's most comprehensive medical necessity database.

ClaimStaker gives healthcare organizations—including physician practices andhospitals—access to essentially the same technology payers use for claim adjudication. By editing claim files prior to submission, ClaimStaker can improve claim validity and cash flow, and demonstrate clinical defensibility.

Taken together, LCD/NCD data provides coverage rules for a small fraction of all possible CPT® codes. ClaimStaker adds an additional proprietary clinical medical necessity database, more than doubling the number of CPT® codes, to cover virtually all possible ICD-9/CPT® code combinations. Based on our medical content database, constantly updated over the course of more than 30 years, ClaimStaker yields a depth of edits no other coding software provider can match.

ClaimStaker Features

ClaimStaker accepts claim files created by most hospital billing and practice management systems. And it requires no change to existing programming. Even though end users maintain their existing billing software, no duplicate data entry is necessary.

Practice Insight offers optional clinical claims scrubbing as a part of the EDIinsight solution. The clinical claim scrubber verifies the technical and coding accuracy before your claims are filed by identifying potential problems that will cause claim rejection or reduction in payment. The clinical claim scrubber provides a comprehensive set of coding and technical edits. Each individual edit may be enabled or disabled completely, for a specific claim type or for an individual payer. Some of these edits include:

  • LMRP medical necessity
• Proprietary medical necessity
• RVU sequencing
• E/M over/under coding
• Correct modifier usage
• CPT/HCPCS/ICD-9 current year validity
• CPT/patient gender suitability 
  • ICD-9 validity, ultimate specificity, secondary code suitability and V-code validity
• Assistant surgeon rules
• Add-on/parent code resolution
• Medicare non-covered services
• Statutorily excluded services 

Detailed, Instructive Reports 

ClaimStaker's detailed reports capture and present all the information necessary to make coding corrections before submitting actual claims. They fully explain the error logic in easy-to-understand terms, providing the appropriate corrective action when possible. The split file feature in ClaimStaker separates good claims, which are ready to submit immediately, from claims that must be corrected. In addition, ClaimStaker reports can be saved as compliance documentation.


Customized Edits 

ClaimStaker's ease of customization truly sets it apart. In addition to accommodating unusual insurance or managed care rules, each standard edit in ClaimStaker can be enabled or disabled for specific claim types or payers with the click of a check box. For sophisticated users who wish to create their own unique edits, an "edit wizard" guides them through the process of creating edits based on a set of parameters that trigger customized messages.


Evaluation and Management Edits 

A unique feature, ClaimStaker can apply an acuity level to each ICD-9 code in a claim—a more reliable way to avoid the compliance risks of over-coding and prevent the revenue loss from under-coding for evaluation and management services.


Software Interface/Integration 

Alpha II implementation specialists and programmers work closely with our provider partners to ensure efficient, effective, and appropriate access to ClaimStaker features—whether it's a quick interface or an in-depth integration. Advanced functionality can be interfaced into our partners' host applications with minimal workflow process modifications and, in many cases, no program modifications. For tighter application integration, ClaimStaker's variety of communication methods and input-output options support embedding of the ClaimStaker edit process to create a work queue displayed within the host application's user interface.


CPT® is a registered trademark of the American Medical Association. All Rights Reserved.
Copyright 2012 MEGAS, LLC and Unicor Medical, Inc.


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