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Claims and approvals

NextHealth Care

Included in Care Clinics Pro and Care Hospitals, and an add-on for Care Clinics

A rejected claim that only finance sees will be rejected again next week. NextHealth Care links each rejection and denial to its reason, payer, clinician and service, so the cause can be fixed where it starts. Eligibility is checked before treatment, prior authorisations are tracked to approval, claims are generated from the codes recorded during care, and payments are posted and reconciled against each claim, with outstanding balances aged automatically.

What it covers

  • Real-time eligibility and benefit check where the payer supports it
  • Prior authorisation request and tracking
  • Claim generation in the payer's required format and standard
  • Rejection and denial management with reason coding and a resubmission workflow
  • Payment posting, reconciliation and ageing
  • Denial trend analysis by payer, clinician and reason
Why it is hard to do well

Claim rejections must reach the people who can prevent them

Insurance claims management that reduces rejections

A payer rejects a run of claims because a diagnosis code does not support the procedure billed. Instead of correcting them one by one month after month, the revenue team sees the pattern in the denial analysis, shares it with the clinicians involved, and the same rejection stops appearing.

Most rejections are preventable at the front of the process: eligibility checked before treatment, authorisations approved before the procedure and codes captured as care is delivered. NextHealth Care builds those checks into the visit, so claims leave complete.

When a claim is rejected, the reason is coded and the claim moves into a resubmission workflow with a clear owner. Payments are posted and reconciled against claims, balances are aged, and denial trends by payer, clinician and reason show exactly where to focus. First-pass acceptance improves and cash arrives sooner. Coders and claims staff work from one queue, so nothing is left sitting in an inbox or a spreadsheet.

How claims management works in NextHealth Care

Insurance claims management software handles the work between a healthcare provider and insurers, from eligibility to payment. In NextHealth Care, it forms the payer side of the revenue cycle and is built on the codes captured during care.

  1. Check eligibility. Coverage and benefits are checked before treatment where the payer supports it.
  2. Authorise. Prior authorisation requests are created and tracked until the payer responds.
  3. Submit. Claims are generated from the visit in each payer's required format and standard.
  4. Resolve rejections. Rejections are coded by reason and moved into a resubmission workflow.
  5. Post and analyse. Payments are posted and reconciled, balances aged and denial trends analysed.

More in NXH Care

12 more modules

Questions we get asked

Claims and approvals is included in Care Clinics Pro and Care Hospitals, and can be added to Care Clinics.

Yes. Eligibility and benefits are checked in real time where the payer supports it, and the result is recorded with the visit.

Yes. Authorisation requests are created and tracked until the payer responds, so procedures are not performed without approval.

Each rejection is recorded with a reason code and moved into a resubmission workflow with a clear owner until it is corrected and resent or closed.

Yes. Denial trends are grouped by payer, clinician and reason, so recurring causes can be fixed at the source.

Yes. Claims are generated from the visit record in the format and standard each payer requires.

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