Standard Operating Procedure: Claim Submission¶

Purpose¶

This SOP defines the standardized process for submitting healthcare claims through NPHIES using BrainSAIT automation.

Scope¶

Applies to all claim submissions for: - Inpatient services - Outpatient services - Emergency services - Pharmacy claims - Dental services

Roles and Responsibilities¶

Role	Responsibility
Clinical Staff	Complete accurate clinical documentation
Medical Coder	Assign appropriate ICD-10-AM and ACHI codes
Billing Specialist	Review and submit claims
RCM Manager	Monitor submission metrics and resolve issues
IT Support	Maintain system integrations

Prerequisites¶

Patient registered in system
Insurance eligibility verified
Clinical documentation complete
Prior authorization obtained (if required)
BrainSAIT agents configured

Step-by-Step Process¶

Step 1: Validate Encounter Completeness¶

Action: Ensure all required clinical documentation is present

Using DocsLinc:

# Validate documentation completeness
completeness_check = await DocsLinc.validate_documentation(
    encounter_id=encounter.id,
    payer_id=patient.insurance.payer_id
)

if not completeness_check.is_complete:
    # Alert clinical staff
    notify_clinical_staff(
        missing_items=completeness_check.missing_items
    )
    return

Required Elements: - Chief complaint - History of present illness - Physical examination findings - Diagnosis - Treatment plan - Procedures performed - Medications prescribed - Discharge/follow-up instructions

Quality Check: Documentation must support medical necessity

Step 2: Generate FHIR Bundle¶

Action: Convert encounter data to FHIR R4 format

# Generate FHIR claim bundle
claim_bundle = await generate_fhir_bundle(
    encounter=encounter,
    patient=patient,
    insurance=insurance_info,
    procedures=procedures,
    diagnoses=diagnoses
)

Bundle Components: - Claim resource - Patient resource - Coverage resource - Encounter resource - Procedure resources - Diagnosis resources - Supporting documentation

Step 3: Run ClaimLinc Validation¶

Action: Pre-validate claim before submission

# Validate with ClaimLinc
validation_result = await ClaimLinc.validate_claim(
    claim=claim_bundle,
    payer_id=insurance_info.payer_id
)

if not validation_result.is_valid:
    # Review and fix errors
    for error in validation_result.errors:
        log_validation_error(
            claim_id=claim_bundle.id,
            error=error,
            severity=error.severity
        )

    # Generate correction report
    correction_report = ClaimLinc.generate_correction_guide(
        validation_result=validation_result
    )

    # Notify billing specialist
    send_notification(
        to=billing_specialist,
        subject="Claim Validation Failed",
        body=correction_report
    )

    return

Validation Layers: 1. FHIR schema compliance 2. NPHIES profile requirements 3. Payer-specific rules 4. Clinical coding accuracy 5. Financial calculations

Step 4: Submit to NPHIES¶

Action: Submit validated claim through NPHIES gateway

# Submit claim
submission_result = await nphies_client.submit_claim(
    claim_bundle=claim_bundle,
    provider_id=provider.nphies_id,
    payer_id=insurance_info.payer_id
)

# Log submission
audit_logger.log_submission(
    claim_id=claim_bundle.id,
    submission_id=submission_result.submission_id,
    timestamp=datetime.now(),
    user=current_user,
    status="submitted"
)

Submission Confirmation: - Submission ID received - Timestamp recorded - Initial validation passed - Claim status: "Pending Adjudication"

Step 5: Track Payer Response¶

Action: Monitor claim status and handle responses

# Poll for claim status
async def monitor_claim_status(claim_id: str):
    while True:
        status = await nphies_client.get_claim_status(claim_id)

        if status.state == "adjudicated":
            # Process EOB
            eob = await nphies_client.get_eob(claim_id)
            process_eob(eob)
            break

        elif status.state == "rejected":
            # Trigger rejection workflow
            await handle_rejection(claim_id, status.rejection_reason)
            break

        # Wait before next poll
        await asyncio.sleep(300)  # 5 minutes

Status Types: - Submitted - Under Review - Pended (additional info requested) - Adjudicated (approved) - Rejected - Partially Approved

Step 6: Handle Rejections¶

Action: Analyze and resubmit rejected claims

# Analyze rejection with ClaimLinc
rejection_analysis = await ClaimLinc.analyze_rejection(
    claim_id=claim_id,
    rejection_reason=rejection_reason,
    rejection_code=rejection_code
)

# Generate resubmission package
resubmission_package = await ClaimLinc.generate_resubmission(
    original_claim=original_claim,
    rejection_analysis=rejection_analysis,
    additional_documentation=additional_docs
)

# Resubmit
resubmission_result = await nphies_client.resubmit_claim(
    resubmission_package=resubmission_package
)

Rejection Categories: - Administrative errors - Clinical documentation issues - Coding errors - Eligibility problems - Policy violations - Technical errors

Step 7: Generate Performance Report¶

Action: Weekly submission performance analysis

# Generate weekly report
report = await generate_submission_report(
    start_date=week_start,
    end_date=week_end,
    metrics=[
        "total_submissions",
        "acceptance_rate",
        "rejection_rate",
        "avg_processing_time",
        "revenue_impact"
    ]
)

# Distribute to stakeholders
send_report(
    recipients=[rcm_manager, billing_team_lead],
    report=report
)

Key Metrics: - Total claims submitted - First-pass acceptance rate - Rejection rate by category - Average time to adjudication - Revenue collected vs. submitted - Top rejection reasons

Exceptions¶

Emergency Claims¶

Expedited submission within 24 hours
Retroactive authorization allowed
Clinical justification required

High-Value Claims (>100,000 SAR)¶

Additional management review
Enhanced documentation requirements
Direct payer communication

Disputed Claims¶

Escalate to RCM Manager
Prepare appeal documentation
Consider external review

Key Performance Indicators¶

KPI	Target	Measurement Frequency
Clean claim rate	>95%	Daily
First-pass acceptance	>90%	Weekly
Average submission time	<2 hours	Daily
Rejection rate	<5%	Weekly
Resubmission success rate	>85%	Weekly

Training Requirements¶

NPHIES platform overview
FHIR R4 fundamentals
BrainSAIT agent usage
Medical coding basics
Payer policy awareness

Revision History¶

Version	Date	Changes	Author
1.0.0	2025-01-15	Initial release	BrainSAIT Team