Eligibility verification
Eligibility checks for BPJS and private insurers with patient identity validation and status tracking.
Eligibility, e-claim, and reconciliation
Rayterton Insurance & Claims (BPJS / Private)
A claims operations platform for BPJS and private insurer workflows. Manage eligibility checks, coverage validation, pre-authorization, claim packaging, coding and grouping readiness, e-claim submission, dispute handling, and payment reconciliation. Reduce claim rejections through clean documentation and automated completeness checks.
Request Claims Demo
Share your BPJS flow, private payer list, and claim pain points, we will prepare a tailored prototype
Operational outcomes
Claim Control
Submission to paid
- Lower rejection and resubmission volume
- Faster claim turnaround time
- Clear dispute handling workflows
- Better cash flow visibility
Front end claim readiness
Eligibility Checks and Coverage Validation
Validate payer eligibility early, apply coverage rules consistently, and reduce downstream claim rejection. Support BPJS and private payer policy constraints for outpatient, inpatient, ED, and procedures.
Coverage and benefit rules
Apply benefit limitations, exclusions, class rules, and coverage mapping per payer contract.
Referral and entitlement controls
Referral requirements, clinic entitlement rules, and documentation completeness checks readiness.
Pre-authorization readiness
Track pre-auth requests, approvals, and validity windows for high cost procedures and admissions.
Guarantee letter management
Generate and track guarantee letters, corporate approvals, and payer commitments readiness.
Eligibility and coverage audit logs
Full audit trails for checks, overrides, and approvals for compliance and dispute support.
Claim packaging
Claim Preparation, Coding, and Completeness Checks
Prepare claims with structured checklists, required documents, and internal validations. Ensure codes, tariffs, and clinical documentation are aligned before submission.
Claims are made or lost in completeness
Missing documents and inconsistent codes drive rejections. Use automated checklists and validation rules to enforce claim readiness before submission.
Connected to EMR and billing
Pull diagnosis, procedures, lab and imaging results, discharge summary, and itemized billing directly from the source systems to reduce manual work.
Document checklist per payer
Required documents by BPJS vs private payer, by service type, with missing item alerts.
Diagnosis and procedure coding
Coding workflows, validation, and versioning readiness aligned to local requirements.
Grouping and claim classification readiness
Support grouping and case classification processes with clear mapping of diagnoses and procedures.
Tariff and benefit validation
Validate billed items against covered benefits, caps, packages, and payer contract rules.
Clinical consistency checks
Check for consistency between diagnosis, procedures, meds, and outcomes to reduce disputes.
Pre-submission approval workflow
Internal approvals for high value claims and exceptions with full audit trails.
e-claim submission
Submission, Tracking, and Resubmission Workflows
Submit claims via e-claim channels, track statuses, and manage resubmissions and corrections through structured queues and timelines.
Submission batch control
Submit claims in controlled batches with numbering, logs, and completeness verification.
Status tracking dashboard
Track submitted, pending, queried, approved, rejected, and paid statuses with aging visibility.
Query and correction workflow
Manage payer queries, correction tasks, supporting documents, and resubmission readiness.
Resubmission management
Versioning and resubmission logs with reason codes, timelines, and approvals.
SLA and aging monitoring
Claim aging and SLA monitoring by payer, service line, and claim value.
Integration readiness
API and connector readiness for BPJS and private payer systems with secure audit logging.
Disputes and reconciliation
Dispute Handling, Payment Posting, and Reconciliation
Manage disputes and underpayments with reason codes, supporting evidence, and negotiation workflows. Post payments and reconcile to billed amounts with variance tracking.
Dispute and appeal controls
- Dispute cases with reason codes and evidence attachments readiness.
- Appeal submissions and follow up tasks with timelines.
- Root cause tracking to improve future claim quality.
Payment posting and reconciliation
- Payment posting by remittance file or manual entry readiness.
- Variance tracking: paid, rejected lines, and adjustments.
- AR aging and cash flow dashboards by payer.
Analytics
Claims Analytics and Revenue Assurance
Monitor claim performance, rejection reasons, and payer behavior to improve revenue assurance and cash flow.
Rejection and query analysis
Top rejection reasons, query categories, and trends by payer and unit.
Claim turnaround time
Measure TAT from discharge to submission and from submission to payment.
AR aging dashboard
Outstanding receivables by payer, aging buckets, and expected collection forecasts.
Underpayment and variance insight
Identify underpayments, package caps impact, and dispute recoveries readiness.
Payer performance scorecard
Payer performance by approval rate, TAT, dispute rate, and payment variance.
Export and BI readiness
Export claim KPIs for enterprise analytics, finance dashboards, and audit reports.