03 Nov Closing the Loop: A Clear Path Forward for Paper Dental Claim Exceptions
As capture technology advances, extracting data from a paper dental claim is becoming increasingly accessible. But anyone who has been around data capture will tell you, the validation of that data is truly where the rubber meets the road. Captured data is great, but it still must meet the payer’s requirements and business rules before the claim can move forward.
What happens when it doesn’t?
A missing identifier, an unsuccessful provider lookup, or incomplete member information can interrupt an otherwise automated process. The claim still requires attention. Someone must take the time to determine what is missing, who can resolve it, and what happens next.
That was the question behind ICS’s recent NADP CONVERGE demonstration, “Closing the Loop: Modernizing Provider Communication for Paper Claim Exceptions.” It is also a question every payer should consider:
What happens to your process flow when the automation stops?
Paper dental claim processing involves more than turning an image into electronic data. Information Capture Solutions (ICS) captures claim information, applies customer-specific validation and business rules, and prepares claims for downstream processing through 837D export.
During that process, ICS uses the submitted claim information along with member and provider lookup resources available to us. Sometimes those resources are not enough to resolve an exception.
For example, a provider identifier may not match the available reference data. ICS may be unable to resolve that mismatch, but the payer may have access to additional provider records or internal information that can supply the answer.
In other cases, neither ICS nor the payer has the information needed and provider input is needed to clarify or correct the submission.
These situations require different next steps. A complete exception workflow needs to support both.
When the payer can help resolve the exception
ICS’s Reject Portal gives authorized customer reviewers a browser-based workspace for reviewing claims that need additional attention. The reviewer can see the claim image, the information ICS has already captured, and the reason the claim requires review.
That context allows the customer to apply information available within its own organization. The reviewer can supply or correct the relevant data and submit the claim back into the ICS workflow.
ICS can then complete the remaining capture and validation steps and prepare the claim for 837D export once the applicable requirements are met.
The distinction matters: successful portal submission is the handoff back to ICS. It does not, by itself, mean that final processing or export has been completed.
For claims that can be resolved this way, customer review provides a path forward without requiring the provider to resubmit information the payer can already supply.
When provider action is required
Some exceptions cannot be resolved through internal review. When the necessary information is unavailable, the workflow needs to communicate the issue to the appropriate recipient.
Within the portal, the customer’s reviewer can select payer-defined letter reasons. Those selections populate corresponding language in the resulting correspondence. Multiple reasons can be included when a claim has more than one issue requiring attention.
This connects the review decision to the communication that follows. The recipient receives claim-specific information explaining why processing could not continue, along with the applicable guidance for review, correction, or resubmission.
The wording matters. A useful letter should help the recipient understand the issue and the next step. Its content should reflect the payer’s requirements and the circumstances of the claim.
ICS can support the outbound printing and mailing of that correspondence as part of the service, extending the workflow from exception review through provider communication.
A workflow shaped around the payer’s requirements
Payers have different business rules, review responsibilities, and communication requirements. The exception process needs to reflect those differences.
ICS’s Reject Portal is built on OpenText Intelligent Capture and uses HTTPS access with authenticated user login. User permissions control which claims and documents each reviewer can access and interact with.
The reasons claims are routed for customer review can be configured around the payer’s requirements. Letter reason selections and their associated language can also be tailored to support the customer’s correspondence needs.
This gives the payer a structured way to contribute information, direct the next action, and communicate with providers when a claim cannot proceed as submitted.
Extending paper dental claims processing through resolution
ICS offers reject review and outbound correspondence as additional services supporting our paper dental claims processing offering.
Together, these capabilities support two practical outcomes:
- The customer supplies the information needed: The claim returns to ICS for completion of the remaining processing steps and preparation for 837D export.
- Provider action is required: The workflow produces claim-specific correspondence explaining the issue and guiding the next step.
The objective is to ensure that a claim that stops during automation still has a defined path forward.
For payers reviewing their current process, a few questions can reveal where that path needs attention:
- Where do claims go when they cannot pass validation?
- Can reviewers access the original claim, captured data, and exception reason together?
- Can the payer supply additional information without requesting a new provider submission?
- Does correspondence explain the actual issue and provide useful next-step guidance?
- Who is responsible for moving each exception forward?
The answers help show whether exception handling is a connected part of the claims workflow or a source of additional manual coordination.
Keep the process moving when automation stops
Automation can take a paper dental claim a long way. A well-defined exception process helps address the information gaps that remain.
By connecting customer review, continued claims processing, and outbound provider correspondence, ICS helps payers extend their workflow beyond capture and give exceptions a clear next step.
If your team is evaluating how to handle paper dental claim exceptions, please feel free to contact ICS to discuss how reject review and outbound print and mail services could support your operation.
606.862.2000
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