Healthcare Workflow Automation

Automated claims preparation, payer portal submission, status monitoring, and rejection handling. Bots extract patient and encounter data from your EHR using FHIR R4 resources -- Patient, Encounter, Observation, and Condition resources for clinical data; Coverage resources for insurance information -- and map the data to the payer-specific claim format. Claim submission uses HIPAA 5010 EDI (X12 837P for professional claims, 837I for institutional claims) via a clearinghouse connection to Change Healthcare, Availity, or Waystar, or direct payer portal submission where EDI is not available.

Status monitoring uses X12 276/277 eligibility and claim status inquiry transactions to check submission and adjudication status on a defined schedule. Rejected claims are returned with the X12 277 rejection code, mapped to a human-readable description, and routed to your billing team's review queue with the rejection reason and suggested correction pre-populated from the rejection code lookup table. For EHR systems that do not expose a claims API, UiPath or Microsoft Power Automate RPA handles the UI-based claim entry workflow, recording each interaction in the audit log. The result is a claims workflow that reduces average days in AR and drops submission error rates by removing the manual transcription steps between clinical documentation and claim submission -- without requiring new billing headcount to absorb volume growth.

Automated prior authorization request submission for surgical procedures, specialty medications, advanced imaging, and durable medical equipment across payer portals. The automation architecture uses two complementary approaches: CDS Hooks (Clinical Decision Support Hooks) for EHR-integrated coverage requirements discovery (CRD) at the point of order entry, and Documentation Templates and Rules (DTR) to automatically populate the authorization request with the clinical documentation the payer requires. For Epic and Cerner environments that support the Da Vinci CRD and DTR implementation guides, this means the authorization workflow is embedded in the clinician's ordering workflow rather than a separate admin process.

For payers and EHR systems not yet supporting CRD/DTR, bots pull the patient demographics, ICD-10-CM diagnosis codes, CPT/HCPCS procedure codes, and supporting clinical documentation from your EHR, complete payer-specific authorization forms via portal automation using UiPath or RPA frameworks, and submit requests automatically. Status checking runs on a defined schedule -- typically every 4 hours -- with escalation to the clinical team when authorization is not received within expected timeframes and an urgent escalation path for time-sensitive procedures. The result is a workflow that takes prior auth from a 25--40 minute manual task per request down to a 3--5 minute exception-review process, with the bot handling all the data gathering and form completion.

Automated data entry from intake forms, referral letters, external records, and lab results into your EHR. For incoming HL7 v2 messages -- ADT A01 admissions, ADT A08 demographic updates, ORM O01 orders, ORU R01 lab results -- the integration engine (Mirth Connect or Azure Health Data Services) parses the message, maps the fields to your EHR's data model, and inserts the data without manual keying. Referral letters and external documents that arrive as PDF or scanned images are processed using OCR (AWS Textract or Google Document AI) to extract structured fields -- patient identifiers, referring provider NPI, diagnosis codes, requested service -- before the extracted data is validated and entered into the EHR.

Cross-system patient record reconciliation applies probabilistic matching when patient records exist in multiple systems without a shared patient identifier. Matching algorithms compare last name (with Levenshtein distance tolerance for spelling variations), first name, date of birth, and zip code to identify likely matches. High-confidence matches are merged automatically; low-confidence matches are routed to a human review queue with the candidate records displayed side by side. For bulk data migration during practice acquisitions or EHR transitions, migration runs are executed in incremental batches with validation checks after each batch: record count reconciliation, data completeness checks against mandatory fields, and sample validation of mapped values against the target system's code sets. Epic FHIR R4 bulk export ($export) handles large-scale data extraction from Epic environments supporting the SMART Backend Services authorization profile.

Automated patient communication workflows triggered by EHR events: appointment confirmations and reminders sent at 72 hours and 24 hours before the scheduled visit, recall notifications when a patient is due for a preventive service or follow-up, lab result release notifications, prescription refill reminders, and post-visit follow-up sequences. The trigger events come from HL7 v2 ADT and SIU (scheduling) messages emitted by your EHR, or from FHIR R4 Appointment and ServiceRequest resources via webhook subscriptions where your EHR supports FHIR R4 subscriptions.

Multi-channel delivery -- SMS via Twilio or AWS SNS, email via SendGrid or Amazon SES, and patient portal in-app notification -- is routed based on the patient's stated communication preferences recorded in the EHR, with channel fallback rules when a preferred channel is unavailable. All outbound messages containing PHI are delivered over secure channels; SMS messages are limited to appointment time and date without clinical detail, with a link to the secure patient portal for sensitive information. HIPAA-compliant patient communication requires that the patient has explicitly opted in to each communication channel and that PHI exposure through that channel is limited to what the patient has consented to receive.

Recall notifications for preventive care are generated by querying the EHR for patients who are due for a service based on age, diagnosis, and last service date -- mammography screening at 40+, colorectal cancer screening at 45+, or HbA1c monitoring for diabetic patients every 3 months. The communication workflow sends the recall, tracks patient response (booked, declined, no response), and escalates unresponsive high-priority patients to a care coordinator.

Automation across the revenue cycle -- from eligibility verification at scheduling through payment posting. Eligibility verification uses X12 270/271 transactions submitted to the payer via clearinghouse at the time of scheduling, and again 24--48 hours before the appointment, to confirm active coverage, co-pay amount, deductible status, and whether the provider is in-network. Exceptions -- inactive coverage, out-of-network status, or coverage requiring prior authorization for the planned service -- are flagged to the scheduling team before the appointment so they can be resolved, not after the visit when the claim fails.

Post-visit billing automation maps the documented diagnosis codes (ICD-10-CM) and procedure codes (CPT or HCPCS) from the clinical note to a superbill, validates code combinations against CCI (Correct Coding Initiative) edits that would trigger claim rejection, and routes the claim for submission via HIPAA 5010 EDI 837P/837I. Electronic Remittance Advice (ERA) via X12 835 transactions handles automated payment posting: matched claims are posted automatically; unmatched payments and contractual adjustments are routed to the billing team's review queue. Denial management automation categorizes denial codes (CO, PR, OA prefix codes in the 835) and triggers the appropriate remediation workflow -- a CO-97 bundling denial triggers a CPT modifier review; a PR-1 deductible denial triggers a patient statement. The revenue cycle automation reduces the manual work between clinical documentation and deposited payment while maintaining the exception review that genuine edge cases require.

Automated assembly of compliance reports from clinical and administrative systems -- HEDIS quality measure reporting for payer value-based contracts, MIPS (Merit-based Incentive Payment System) performance data for CMS, payer-specific data submissions, state-mandated public health reporting, and HIPAA breach notification documentation. Data is extracted from source systems, validated against the measure specification, and assembled into the required submission format automatically on a defined schedule.

Every automated action in the system generates a structured audit log entry: the actor (bot identifier and version), the action taken (read, write, submit, update), the data accessed (patient identifier, record type, field names), the timestamp, and the outcome. Audit logs are stored in append-only, tamper-evident storage -- CloudTrail on AWS or Cloud Audit Logs on GCP -- with a minimum 6-year retention period as required under HIPAA. This means every automated claim submission, every prior auth request, and every patient record access by the automation system is documented and retrievable for a compliance audit or legal hold without manual reconstruction.

HIPAA compliance monitoring runs continuous checks against the architecture: access pattern anomaly detection to flag unusual data access volumes, encryption validation to ensure no PHI is written to unencrypted storage, and BAA coverage verification to confirm that any new third-party service introduced to the system is covered by a signed BAA before PHI is routed to it. The compliance reporting layer gives your compliance team reviewed output, not raw data to assemble -- reducing the staff time required per reporting period from days to hours.