The Claim Loop

ClaimPod does not receive claims. It receives the ingredients your practices already produce, and builds claims from them. The loop below is the whole product in one page.

flowchart TD
  A[Files arrive] --> B[Patients and visits]
  B --> C[Claim generated]
  C --> D[Ready to file]
  D --> E[Filed as EDI]
  E --> F[Payment posted]

  A <-. a row ClaimPod cannot resolve .-> R1(["Import review"])
  C <-. findings to clear .-> R2(["Claim review"])
  E <-. a payment that does not fit .-> R3(["Remittance review"])

  classDef human stroke-width:3px;
  class R1,R2,R3 human;

The three rounded boxes are the only places a person is asked for anything. Everything else runs whether you are watching or not, and the sections below say what each stage does.

Data Arrives and Is Staged

Files land from a folder, an SFTP drop or a bucket, and a mapping template translates each file shape into patients, visits and services. Rows are staged and validated before anything reaches your live data. Clean rows flow straight through.

Problem Rows Stop

A row ClaimPod cannot resolve on its own becomes a work item rather than a silent failure or a bad record. Ambiguous patient identity, a conflicting field, a code it does not recognise: these wait for a person, and only that person’s decision lets the row through.

Claims Are Generated, Not Typed

Once a visit has what a claim needs, ClaimPod builds the claim from it. Nobody keys a claim by hand, so a claim always says what the visit said.

Rules Check Every Claim

Generated claims are checked against the client’s review rules. Claims that pass promote themselves to Ready without anyone opening them. Claims that fail arrive as work items with each finding painted on the exact field at fault.

This is the ratio the product exists to change: a billing operation that reviews every charge by hand, to one that reviews only what a rule stopped.

Ready Claims Are Filed

Ready claims collect into an export batch, which produces a real EDI claim file with proper control numbers. Batches never change after the fact. A retry is a new batch, so the history stays honest about what was sent and when.

Remittances Come Back and Post

When the payer’s remittance arrives, clean payments post automatically. Anything anomalous is held for a person instead of quietly booking money against the wrong claim.

Related: Claims · Imports · Work Queues