How does eligibility checking and the claims workflow work?

The Insurance billing module (/apps/insurance) covers eligibility verification and claims management end to end. Signing an encounter with accepted ICD-10 codes auto-creates a claim. Here is what the workflow looks like in practice.

Six tabs, what each one does

The Insurance module has six tabs:

Dashboard. Total billed, total collected, outstanding balance, pending and denied claim counts, status distribution and collection trend charts.
Claims. The full claims management table. Filter by status, payer, provider, date range. Per-claim actions for view detail, resubmit, appeal, mark as paid.
Eligibility. Real-time insurance verification. Run a check before a visit or in batch.
Reports. Aging by payer, collection rates, denial analysis.
Enrollment. Provider credentialing and payer network participation.
Ledger. Workspace-level financial view across all patients and payers.

The workspace-level data here mirrors what you see in the patient-level views (/patient/<uuid>/insurance and /patient/<uuid>/ledger), kept in sync across both views.

Running an eligibility check

Open the Eligibility tab. You can verify a single patient or batch-verify a set. The check returns:

Coverage active status (active, inactive, terminated).
Deductible (annual, met, remaining).
Copay or coinsurance.
Out-of-pocket maximum.
Covered services for the relevant procedure codes.

Most practices run eligibility 24 to 48 hours before each scheduled visit. Some run it the morning of the visit as a final check. The choice is a workflow decision based on how much advance notice your front desk needs to communicate cost-sharing to the patient.

The eligibility check itself is real-time and typically returns in under five seconds.

How claims are created

When you sign an encounter with accepted ICD-10 codes and a CPT or service code, the system auto-creates a claim. The claim contains:

Patient demographics from the patient record.
Service date and provider from the encounter.
Service location (if assigned).
Diagnosis codes (primary first, then comorbid, then chronic conditions monitored but not actively treated).
Procedure codes from the encounter or the time-based defaults.
Add-on codes that the system suggested and you accepted.

The claim moves to Pending status while it is queued for submission. Most practices submit claims in batches at end-of-day or end-of-week. Submission is handled inside the Claims tab.

Claim status flow

Pending -> Submitted -> Accepted -> Paid (or Denied)
                                 -> Partially Paid

Each claim has a status badge in the Claims tab. The transitions:

Pending: created, not yet submitted to a payer.
Submitted: sent to the clearinghouse and accepted by it.
Accepted: accepted by the payer for adjudication.
Denied: rejected by the payer. The reason code is visible in the claim detail.
Paid: payer paid in full.
Partially Paid: payer paid less than the billed amount; the difference is the patient responsibility or a payer adjustment.

Resubmissions and appeals

A denied claim has two paths. Resubmit is for fixable errors (missing information, wrong code, eligibility mismatch). Appeal is for substantive disagreement with the denial reason. Both paths are inside the claim detail page.

The system tracks the full history. A claim that was denied, fixed, and resubmitted shows the chain in the claim timeline so you can see what happened and why.

Reports and aging

The Reports tab is where practice administrators spend most of their time. The standard reports:

Aging by payer. Outstanding balance bucketed by 0 to 30, 31 to 60, 61 to 90, 91 plus days.
Collection rate by payer. Percentage of billed amount collected.
Denial analysis. Denials grouped by reason code, payer, and provider, with drill-down to specific claims.

These reports support the financial review most groups run weekly or monthly.

Enrollment

The Enrollment tab tracks provider credentialing across payers. Fields per provider include NPI, payer, enrollment status, effective date, and credentialing contacts. Most practices use this as a reference, not an active workflow surface; the actual credentialing happens with the payer.

Common questions

Can the system bill across multiple payers per encounter? Yes. Coordination of benefits is supported per claim.
Does the system handle Medicare and Medicaid? Yes, with payer-specific rule sets active by default for those programs.
Can I modify a claim after submission? Not directly. Submitted claims need to be canceled (by the payer or the clearinghouse) and resubmitted.

For specific billing questions, email hello@nextvisit.ai. Complex coordination-of-benefits scenarios and payer-specific edge cases benefit from a direct conversation rather than a help article.