1 · Validate before release →
Check outbound 837 data against applicable HIPAA transaction and code-set requirements, claim edits, and approved payer rules.
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Bring claim quality, expected reimbursement, payment variances, and account history into one collector workflow—so every follow-up begins with the facts and a clear next action.
Check outbound 837 data against applicable HIPAA transaction and code-set requirements, claim edits, and approved payer rules.
Apply effective contract terms as the claim leaves the scrubber. Make the calculation available before collections begins.
Connect acknowledgments, claim status, and 835 remittances to the original claim. Surface rejections, denials, and payment differences.
Route work, document outcomes, and turn recurring problems into reviewed billing edits and evidence for payer meetings.
Four eligible days × $3,000 = $12,000 expected. On $20,000 in charges, the contract supports an $8,000 allowance. The 835 reports $10,000 paid and a $10,000 CO-45 adjustment.
Integrate with host systems, scrubbers, and clearinghouses to check claim structure, required data, identifiers, and applicable code sets before release. Route failed checks for correction and validate the corrected claim again.
Connect 837 submission, 999/277CA acknowledgments, claim-status responses, and 835 remittances. A clean technical acknowledgment is not a guarantee of coverage or payment.
Maintain versioned payer profiles using provider manuals, contract provisions, effective dates, and daily feedback from claim responses. Identify new rejection patterns and inconsistent payer behavior.
Propose edits for billing review, preserve the source behind each rule, and test changes before adoption. Payer preferences do not override applicable standards, clinical accuracy, or contract terms.
Evaluate Medicare Advantage coverage decisions against applicable CMS requirements, NCDs/LCDs, permitted plan criteria, and the patient’s documented circumstances. Evaluate payment obligations against the applicable contract.
Route questionable decisions to clinical, coding, contracting, or compliance specialists. Package recurring issues with affected accounts, dollars, dates, payer responses, and supporting evidence for Joint Operations meetings and escalation.
Compact PCE and Account-at-a-Glance views; account search by name, account number, or MRN; session-based previous-account navigation; account phone contacts; and browser-phone and text-conversation components. Client access follows assigned permissions. Calling and messaging depend on their configured services and approvals.
Extend the workspace with contract-driven priority queues, versioned expected reimbursement, payer-profile edit feedback, specialist review handoffs, and payer meeting packages. The intended experience pairs collector call controls with management-only live and saved transcript review, plus consent-aware Message Control campaigns. Availability depends on implementation and connected systems.
Every account tells a story. Exigen connects it.
From the first claim edit to the final payment, give teams the information to resolve today’s account and prevent tomorrow’s repeat problem.
Explore Expected Reimbursement · Denial Management · Contract Management · Payer Projects & Underpayments
Examples are illustrative, with no patient liability or other-payer allocation. CO-45 can be a legitimate adjustment; the amount must be compared with supported contract terms. A Medicare Advantage denial or payment difference alone does not establish noncompliance. Coverage criteria and negotiated payment terms require separate review.
References: CMS transaction standards · CMS Medicare Advantage coverage guidance.