Find issues while your team can still correct them
A claim may need review because a procedure and diagnosis do not align, required information is missing, or an applicable payer rule has not been met. Claim Shield brings findings into the pre-submission workflow so staff can focus their review.
It supports the review process; final reimbursement decisions remain with the payer.
What your team can review
Eligibility and member identification
Review eligibility-related claim information and insurance member identifiers for issues that need attention before submission. The available checks depend on the information and rules configured for the implementation. For patient-registration eligibility verification, also explore eElig.
Pricing and copay
Check claim pricing and copay information against the applicable configured pricing and patient-share rules. Flag discrepancies for billing-team review and correction.
Duplicate claims and services
Identify potential duplicate claims or service entries for review. Help teams reduce duplicate submissions and avoid repeating work; a flag should be assessed against the encounter and supporting records before a service is removed.
Follow-up checks
Review follow-up-related claim and service rules to identify entries requiring clarification or correction. The specific follow-up scenarios and time windows are defined during implementation.
Diagnostic-test time periods
Flag diagnostic tests for review against configured repeat-test intervals and time-period rules. Review the clinical documentation and applicable requirements before deciding how to resolve a finding.
Medical review roadmap
Guide medical reviewers through the flagged issues, supporting claim details and next review steps. The roadmap supports professional review and appropriate corrections within the facility's workflow.
Diagnosis and procedure relationships
Review CPT and ICD combinations and investigate flagged relationships before submission.
Coding edits and validation rules
Review supported coding edits, including MUE and Excludes1 checks where applicable to the relevant coding version and payer requirements.
Payer-specific checks
Apply configured checks for the payer and workflow covered by your implementation. Confirm the supported rule sets and update process during the demonstration.
Findings your team can act on
Review the flagged issue, check the source documentation, make an authorised correction and validate the claim again.
A practical pre-submission workflow
- Bring the claim into the agreed validation workflow.
- Run configured technical, financial, eligibility, duplicate, timing and coding checks.
- Use the medical review roadmap to review findings with the appropriate billing, coding or medical specialist.
- Correct the claim or supporting documentation where appropriate.
- Recheck before continuing submission through your facility's agreed process.
Connect prevention with revenue analysis
Claim Shield focuses on review before submission. RiteRCM brings claim, denial, payment and ageing information into financial and operational dashboards. Together, the intended workflow helps teams investigate recurring problems and prioritise preventive improvements.
Explore RiteRCM analytics, eElig eligibility verification and the RCM Toolkit.
Questions to cover in your demo
- Which claim formats and import methods does our implementation support?
- Which coding versions and payer rules are included?
- How are findings explained and assigned for review?
- Who maintains the rules and how are updates tested?
- How does this fit with our current submission and reconciliation systems?
Frequently asked questions
What is a medical claim scrubber?
A claim scrubber checks claim information against configured validation rules before submission. Its purpose is to flag issues for review and correction.
Which technical checks does Claim Shield cover?
Its scope includes eligibility-related checks, member ID, pricing, copay, potential duplicates, follow-up rules and diagnostic-test time periods, alongside coding checks and a medical review roadmap. Confirm the rules and data sources configured for your facility during the demonstration.
Can Claim Shield help reduce duplicates?
It flags potential duplicate claims or services so the team can investigate before submission. Actual reductions depend on the facility's data, rule configuration and review process; no numerical reduction is promised.
Is claim scrubbing the same as denial management?
Claim scrubbing takes place before submission. Denial management investigates and follows up claims after a payer rejects or denies them. Insights from denial review can inform preventive checks.
Does a scrubber guarantee payment?
No. Validation can help identify issues, but eligibility, coverage, authorisation, documentation, contract terms and payer decisions also affect payment.
How does Claim Shield differ from RiteRCM?
Claim Shield is presented as a pre-submission validation tool. RiteRCM is presented as a revenue cycle analytics and management platform. Confirm the exact modules included in your proposed implementation.
See your claim-review workflow in a demonstration
Tell us about your facility, claim volumes and existing systems. We will explain the available checks and the implementation scope.
Do not send patient or identifiable claim information through the website enquiry form.