Clean-Claim Intake Agent
Runs submitted claims through front-end validation, eligibility, benefit application and coordination-of-benefits sequencing.
An 837I lands through the clearinghouse and four questions have to resolve before anything moves: does it parse, was the member covered on the dates of service, is this plan primary, and which statutory clock just started. The claims examiner of record commits administrative denials only, eligibility, benefit exclusion, timely filing and no authorization on file; anything turning on medical necessity, level of care or experimental status leaves for clinical review and is a clinician's act. A claim failing front-end validation returns on the 277CA as a rejection, short of adjudication and carrying no appeal rights; providers appeal them anyway, and explaining the difference is standing work.
Authority
Execute within policy
Team role
Routes work to specialists
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Health Claims, Appeals & Payment Integrity
Desk workflow
Validate and adjudicate the claim on the right statutory clock, edit and price it, pay it or route the exception, defend the determination through appeal or dispute resolution, then pursue what was overpaid or coordinated wrong, with an independent re-derivation standing between a payment integrity finding and a recovery.
Collaboration
Moves work through defined stages
Decision boundary
Acts only inside a defined mandate and action boundary.
Systems and capabilities involved
Availity Essentials clearinghouse feed
837P and 837I intake with TA1, 999 and 277CA acknowledgments
TriZetto Facets adjudication core
eligibility, benefit package, accumulators and pend codes
270/271 eligibility and 834 enrollment feed
coverage spans, retroactive terms and grace-period status
State prompt-pay and clean-claim rule library
Handoffs
What this role gives and receives
Capabilities offered
Clean-claim determination and clock start
Sorts a submitted claim into adjudicable or pended, records what it pends for, and fixes the statutory clock that governs it.
- Receives:
- 837 transaction, member and provider identifiers, benefit configuration and other-coverage register
- Returns:
- Acknowledgment disposition, clean or pend status with reason, primacy sequence, and the governing clock
Handoff to
Handoff to
Receives from
Receives from
External handoff
Claims examiner of record
External handoff
Claims operations officer
Context
What the role needs to do the work
- Current work
- Acknowledgment state, eligibility span, benefit package, accumulator position, pend reason and the clock started on this claim.
- Prior interactions
- Prior submissions, corrections and pend history for the same claim control number and provider.
- Policies and reference
- State prompt-pay definitions of a clean claim, plan benefit configuration, and coordination-of-benefits order rules.
- Working method
- Pend routing by reason code, line of business and queue ownership.
Illustrative workflow
How the work moves
Starting point
An 837I for a four-day inpatient stay arrives through the clearinghouse for a marketplace member who stopped paying premium in June.
- 01
Confirm the interchange and transaction set acknowledged clean on the TA1 and 999 and that the claim reached adjudication rather than bouncing on the 277CA.
- 02
Resolve eligibility for the dates of service and find the member in month two of the ninety-day advance premium tax credit grace period.
- 03
Apply the grace-period pend rather than adjudicating to payment, and record the notice to the provider that the claim may ultimately deny.
- 04
Start the state prompt-pay clock, sequence primacy against the spouse's group coverage, and hold the claim in the grace-period queue.
Result
A pended claim carrying its clock, its pend reason and its provider notice, visible to the claims examiner of record, who commits the administrative denial if one follows; anything turning on medical necessity leaves for clinical review instead.
Checks and boundaries
What must be tested or reviewed
- 01No payment releases for a member in month two or three of the ninety-day advance premium tax credit grace period without the pend rule applied, and a grace-period pend is never dressed up as a medical necessity denial.
- 02Clock derivation is checked against golden claims in three states and four lines of business, covering the state prompt-pay window, the No Surprises Act thirty-calendar-day initial payment clock, and how each state treats time a claim spends pended.
- 03Rejection and denial discipline is tested both ways: a front-end failure returns on the 999 or 277CA without adverse benefit determination language, and a claim that entered adjudication is reported as adjudicated.
- 04Coordination-of-benefits sequencing is graded where the plan is secondary, where other coverage is suspected but unconfirmed, and where the member left the questionnaire unanswered.
- 05Denial-authority routing is scored on a mixed post-service corpus: administrative defects (eligibility, benefit exclusion, timely filing, no authorization on file) stay with the claims examiner of record, and a claim whose only defect is medical necessity, appropriateness, level of care or experimental status never reaches a terminal state here but leaves for clinical review with its clock intact.
Human authority
- The claims operations officer owns the release authority schedule and the tolerance bands.
- The claims examiner of record commits administrative denials only: eligibility, benefit exclusion, timely filing, and no authorization on file.
- Anything turning on medical necessity, appropriateness, level of care or experimental status routes to clinical review and is committed by the plan medical director or a designated physician reviewer, never here.
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