Insurance & Claims: Scheme rules, pre-authorisation, claim batching and revenue-cycle follow-up

Claims and prior authorisation for SHIF, NHIF and private insurers: a claims register with ageing, the full claim lifecycle from draft to paid with rejection codes and appeal deadlines, clinical coding, pre-authorisations, and a prior-auth engine with documentation checklists, electronic submission logs, appeals, coverage rules and auto-fire rules.

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Billing & Cashiering

Insurance & Claims in the Bridge HMS Suite: Scheme rules, pre-authorisation, claim batching and revenue-cycle follow-up

Approved before the patient is treated

Pre-authorisations requested from the ward or theatre — active, approved, rejected and expired — with the approved amount carried onto the bill.

Prior authorisation by the rules

The prior-auth dashboard, PA requests raised automatically when an order needs one, with documentation templates, and appeals of denials.

Codes and coverage rules

Procedure codes, coverage requirements per payer and the auto-fire rules that open a PA request on their own.

Every service priced and routed

The RCM dashboard, the charge master with codes and prices, router rules that send each charge to the right payer, the DRG grouper and A/R ageing by payer.

Denials worked, write-offs controlled

Write-offs with approval, denials worked to resolution, denial reasons analysed, and payer contracts with their rates.

What's inside

Everything in Insurance & Claims

49 items in 9 areas, every one shipping with the app today.

Pre-Authorization
- Pre-Auth Request RecordsDedicated pre-authorization record with an auto-numbered reference (PA/YEAR/nnnnnn sequence) for every insurer authorization request.
- Service-Type ClassificationTags each request as consultation, lab, imaging, surgery, admission, chemotherapy, dialysis, maternity or other.
- Clinical Justification CaptureMandatory free-text medical-necessity justification enforced before a pre-auth can be submitted.
- ICD-10 & Procedure CodingAttach multiple ICD-10 diagnoses and insurance procedure codes to substantiate the request.
- Supporting Document AttachmentsUpload any number of supporting files to the pre-auth.
- Estimated Amount & CurrencyRecords an estimated cost with per-company currency and constrains it to be non-negative.
Claims Lifecycle
- Insurance Claim RecordsClaim records with an auto-numbered claim number (CLAIM/YEAR/nnnnnn) unique per company.
- Auto-Creation from BillingInvoicing a bill auto-creates a draft claim whenever the bill carries a policy and insurance amount.
- Automatic Charge PullPulls every non-canceled charge with an insurance share onto the claim and derives service date-from/to from them.
- 11-State Claim LifecycleDraft, submitted, in-review, approved, partially approved, rejected, paid, partially paid, appealed, closed and canceled with enforced transitions.
- Filing-Deadline EnforcementBlocks submission of claims past the scheme's filing-deadline window and prompts recording a past-filing rejection instead.
- Full & Partial ApprovalApprove in full or record a partial approval that must be strictly between zero and the claimed amount.
Appeals
- Claim Appeal RecordsAppeal records with an auto-numbered reference (APP/YEAR/nnnnnn), linked to the source claim.
- Appeal from RejectionLaunches an appeal wizard directly from rejected or partially-approved claims, pre-filling claim and date.
- 8-State Appeal WorkflowDraft, submitted, under review, upheld, overturned, partially overturned, final rejection and withdrawn states.
- New-Documentation AttachmentsAttach fresh supporting documents specific to the appeal submission.
- Decision Drives Claim StateUpheld reverts the claim to rejected, overturned re-approves it, partial overturn sets partially approved with a revised amount, final rejection closes it.
- Revised Approved AmountCaptures the insurer's revised approved figure and writes it back to the claim on overturn.
Batches & Submission Channels
- Claim Submission BatchesClaim batches group claims per scheme, facility and period with a BATCH/year/month/seq number.
- Six Submission ChannelsPaper form, e-mail PDF, national insurer APIs such as NHIF and SHA/SHIF, corporate API and payer portal transport options.
- Auto-Attach to BatchOn submission, claims auto-attach to (or create) a draft monthly batch when the scheme has auto-submit-batched enabled.
- Batch PDF GenerationPrints a batch cover PDF and stores it as an attachment on the batch.
- E-mail PDF SubmissionEmails the batch PDF to the scheme's claims-inbox address with an auto-composed cover letter.
- Batch Totals RollupStored computed claim count and total claimed/approved/paid aggregated across batch claims.
Payment Reconciliation
- Reconciliation StatementsReconciliation records (REC/YEAR/nnnnnn) capture an insurer payment statement per scheme and date.
- Statement Line ItemsLine record holding each payment reference, statement amount and matched claim/amount.
- Auto-Match EngineMatches unlinked statement lines to open claims by payment reference and scheme, capping the matched amount at approved/claimed.
- Matched vs Unmatched TotalsStored computed matched total and remaining unmatched balance against the statement's total paid.
- Post to ClaimsPosting a fully-matched statement writes matched amounts to claims, sets payment-advice ref and marks each paid.
- Post-GuardBlocks posting until every statement line is matched to a claim, and prevents canceling posted reconciliations.
Insurer API Integration
- National Insurer API Client (SHA/SHIF)A transport-safe insurer API client with configurable base URL, client ID and secret per scheme for sandbox, UAT and production.
- Pre-Auth API SubmissionPosts pre-auth payloads (member, service type, ICD-10, procedures, justification) and stores the returned insurer reference.
- Claim & Batch API SubmissionSubmits individual claims and whole batches over REST and captures the insurer's reference number.
- Retry & Timeout HandlingHTTP calls retry once on transport errors with a 30-second timeout and surface unrecoverable failures as user errors.
- Offline Simulation ModeWhen the requests library is absent, returns deterministic stub responses so offline staging and tests still succeed.
- Claim Status PollingClaim status checks and an open-claims sync refresh open claims from the insurer, auto-approving or rejecting based on the returned status.
Configuration & Catalogs
- Scheme Claim-Channel ConfigExtends insurance schemes with claim channel, API base URL, client-id/secret, API key and claims-inbox e-mail.
- Filing & TAT ParametersPer-scheme filing-deadline days, average payment turnaround days and historical approval-rate percentage.
- Pre-Auth ThresholdConfigurable monetary threshold above which pre-authorization becomes mandatory for a scheme.
- Preferred Coding SystemPer-scheme choice of ICD-10 WHO, NHIF catalog, CPT, SNOMED-CT or SHA/SHIF catalog.
- Scheme Claim CountersComputed claim and paid-claim counts per scheme with an Open Claims button.
- Procedure Code CatalogA procedure code master with code, description, category, coding system, indicative price and long description.
Cross-App Integration
- Bill Claim LinkageAdds claim list, claim count and a pending-claim flag to hospital bills with a smart button to view claims.
- Patient Claim DashboardAdds patient-level counts of submitted, paid and pending claims plus total claimed and insurer-paid amounts with view buttons.
- Visit Pre-Auth RequirementWorks out whether a visit needs pre-authorization from scheme rules and inpatient type, with a pre-auth count and view button.
- Visit & Bill Claim NavigationContext-aware actions open claims/pre-auths pre-filled with the visit's or bill's patient, policy and facility.
More in this app
- Claims from draft to paid, without the chaseAll claims with their ageing; draft claims built from the visit bill and coding, submitted to SHA, NHIF or the private insurer, approved and finally paid.
- Rejections appealed, payments matchedRejected claims with the insurer's code and appeal deadline, claim batches per insurer, appeals tracked to the end and payment reconciliation of the remittance against each claim.
- Where the money is stuckClaims, pre-auths, appeals, PA requests, batches and reconciliation in pivot and graph — ageing by insurer, rejection reasons, days to payment.

Works with

What Insurance & Claims works with

Insurance & Claims shares one database with the rest of the Bridge HMS Suite and BridgeERP: these are the apps it already talks to, with nothing to buy in between.