Before a medical insurance claim is submitted, several teams may contribute information: reception, clinicians, coding, billing and finance. A structured scrubbing checklist gives reviewers a shared way to identify items requiring attention and decide who should resolve them.
The checklist below describes review areas to discuss when evaluating claim-scrubbing software. The rules applied must fit the relevant claim context, payer arrangements and current requirements. A finding needs an explanation and an accountable next step.
1. Eligibility and member identification
Check the eligibility-related information and member ID associated with the claim. Where a mismatch or unclear result is found, route it to the team able to verify the source information.
Keep registration verification and claim-stage validation connected but distinct. eElig supports portal-based insurance eligibility verification at registration. Claim Shield includes eligibility-related and member-ID checks within its claim-scrubbing scope.
2. Pricing and copay
Review pricing and copay against the applicable arrangements for the claim. In a demonstration, ask which data and configured rules support each finding, how a reviewer understands the issue and what happens when the reference information needs clarification.
Avoid treating a generic example as a rule for every insurance plan. The source, scope and maintenance of the applicable rules matter as much as the warning displayed.
3. Duplicates and follow-up
Duplicate review should give staff enough context to investigate a suspected repeated charge. A flag is a prompt for review; the reviewer needs to determine whether the underlying records represent a duplication or a legitimate circumstance.
Claim Shield includes duplicate and follow-up checks. Ask the team to demonstrate the relevant scenarios for your facility. Exact follow-up conditions should be agreed during scoping rather than assumed from a product label.
4. Diagnostic-test time periods
Review diagnostic-test timing against the applicable rule set. Ask what interval is being checked, what source supports it and how exceptions are handled by the review process.
Claim Shield’s confirmed scope includes diagnostic-test time-period checks. No single interval should be presented as universally applicable across tests, clinical circumstances and payers.
5. Coding and medical review
Claim Shield’s review scope includes CPT/ICD checks, MUE and applicable audit rules, together with a medical review roadmap. Ask to see how findings are explained and assigned for review.
A roadmap should make the next action clear to the responsible team. Software findings do not replace an appropriate professional assessment or guarantee claim acceptance. Confirm the exact criteria and workflow required for your operation during the demonstration.
Turn findings into a manageable work queue
Agree who reviews each type of issue, what constitutes a resolved finding and what evidence supports release for submission. Evaluate whether your proposed workflow makes unresolved items easy to identify and explain.
In Abu Dhabi, the Department of Health’s Shafafiya portal publishes data-exchange standards and technical specifications. Its prices and reimbursement resources provide a place to consult the relevant published materials. Always identify the requirements applicable to your own setting; this checklist is not a substitute for them.
Measure the process consistently
Useful pilot measures include findings by category, time spent reviewing a finding and issues identified again after submission. Define the denominator and comparison period before drawing conclusions. No reduction percentage is claimed here.
For broader outcome analysis, explore RiteRCM. To review the scrubbing workflow itself, request a Claim Shield demonstration using synthetic claim examples.