Insurance Claims

February 2026 · 8 min

Overview

Bio-Ecko manages the complete insurance claims lifecycle -- from patient eligibility verification at registration through pre-authorization, claim submission, follow-up, and settlement posting. The system supports private insurers, TPAs (Third-Party Administrators), government schemes (CGHS, ECHS, PMJAY/Ayushman Bharat, state schemes), and direct corporate tie-ups.

Payer master configuration defines package rates, excluded services, co-pay percentages, room-rent caps, and document requirements per scheme. This eliminates manual rate lookups and ensures accurate billing from the first encounter.

1Verify policy

TPA, plan, patient eligibility, and limits are checked.

2Pre-authorize

Clinical summary and estimate are submitted before planned care.

3Package claim

Bills, reports, discharge summary, and coding are assembled.

4Submit

Claim is sent to the payer or TPA with tracking reference.

5Resolve query

Missing documents and payer questions are answered.

6Settle

Approved amount, disallowance, and patient balance are posted.

Control paths

CashlessReimbursementRejected claim appeal

Setting Up Insurance & Payer Master

Navigate to Settings > Insurance > Payer Master to configure each payer:

• Company & TPA details -- Name, address, contact, claims desk email, and portal URL.
• Scheme variants -- Multiple plans under one payer (e.g., Gold, Silver, Platinum with different room-rent caps and coverage limits).
• Tariff mapping -- Map hospital services to payer-approved rates. Where the payer rate differs from your standard rate, the system auto-calculates the patient-payable difference.
• Co-pay / deductible rules -- Percentage or fixed amount borne by the patient, configurable per service category.
• Exclusions -- Services not covered (cosmetic, experimental, pre-existing conditions during waiting period).
• Pre-auth requirements -- Which procedures need prior approval and the mandatory document checklist.
• Credit period -- Expected settlement days (30/45/60) for ageing calculations and cash-flow projection.
• Network status -- Whether your hospital is on the payer's empaneled network.

The payer master is the foundation for accurate claim processing. Invest time in setting it up correctly.

Eligibility Verification & Pre-Authorization

At Registration / Admission:

1. Select the patient's insurance policy from their profile.
2. Click Verify Eligibility -- the system checks policy validity, remaining sum-insured, waiting-period status, and sub-limits.
3. For PMJAY, this connects to the NHA portal for real-time verification using ABHA ID.
4. If eligible, the scheme rates auto-apply to the encounter.

Pre-Authorization Workflow:

1. Doctor raises a procedure/admission request.
2. Billing team opens Pre-Auth Request > selects payer > attaches clinical notes, investigation reports, cost estimate, and doctor's recommendation.
3. Request is submitted electronically (payer portal integration) or as a PDF package via email.
4. TPA responds: Approved (full/partial), Rejected, or Query (requesting additional information).
5. Approved amount and authorization number are recorded and linked to the bill.
6. Amount above the approved limit becomes patient-payable, visible to the patient at admission.

Pre-auth status is displayed on the patient dashboard, admission screen, and billing screen so all teams stay aligned.

Claim Submission & Tracking

After discharge (IPD) or visit completion (OPD):

Claim Assembly:

• The system auto-populates patient demographics, policy details, authorization number, itemized bill, and supporting documents.
• The bill is validated against payer rules: room-rent capping, package inclusions/exclusions, co-pay calculation.
• Supporting documents are attached: discharge summary, investigation reports, operative notes, pre-auth letter, consent forms.

Submission:

• E-Claims Portal -- Direct upload to the TPA's portal (where integration exists).
• Email -- System generates a claim PDF bundle.
• Physical -- Printed claim forms for courier.

Tracking Dashboard: Each claim progresses through: Draft > Submitted > Under Review > Query Raised > Settled / Partially Settled / Rejected. The dashboard shows counts by status with ageing. Claims past the expected credit period are highlighted. Query responses can be tracked and responded to within the system.

Settlement & Disallowance Management

When a payer remits funds:

1. Go to Claims > Record Settlement > enter UTR/cheque details and amount.
2. Match settlement against claims -- single or batch matching.
3. Disallowances (deductions by TPA) are categorized:
   • Non-payable items.
   • Rate difference (payer rate < hospital rate).
   • Documentation deficiency.
   • Co-pay / deductible deduction.
   • Package inclusion (item already covered under the package).
4. Patient-payable balance (co-pay + disallowance) transfers to the patient's outstanding.
5. GL entries post automatically: reduce insurance receivable, credit bank, post disallowance to expense.

Disallowance Appeal: For unjust deductions, raise a re-submission/appeal within the system. Track appeal status and final resolution.

Government Schemes

PMJAY (Ayushman Bharat):

• ABHA ID verification, HBP (Health Benefit Package) codes, pre-auth via NHA portal, claims through TMS.

CGHS / ECHS:

• Card verification, referral letter validation, CGHS-approved rate card, government-format claim forms.

State Schemes:

• Configurable per state: Aarogyasri (Telangana), Mahatma Jyotiba Phule (Maharashtra), Chief Minister's scheme (Tamil Nadu).
• Each scheme's rate card, document requirements, and portal integration are separately configurable.

Employer/Corporate:

• Direct tie-up billing where the employer is invoiced monthly. Employee co-pay rules and annual caps are configurable per corporate.

Reports & Analytics

• Payer-wise Revenue -- Billed, settled, outstanding, and disallowed amounts per payer.
• Claim Ageing -- Outstanding claims by 0-30, 31-60, 61-90, 90+ day buckets.
• Disallowance Analysis -- Top deduction reasons by payer. Use this to negotiate better contracts.
• Pre-Auth TAT -- Average turnaround for approvals per TPA.
• Settlement Ratio -- Percentage of billed amount actually realized per payer.
• Scheme Utilization -- Beneficiary count, package utilization, and revenue per government scheme.
• Projected Collections -- Based on submission dates and payer credit periods, forecast expected inflows for cash-flow planning.

Notes

Related topics