What steps would you take to perform a quick health-check of the Resolute billing module after a payer switch?

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Multiple Choice

What steps would you take to perform a quick health-check of the Resolute billing module after a payer switch?

When a payer switch happens, the quickest effective health-check is to validate end-to-end compatibility with the new payer setup. Start by reviewing payer mappings to ensure the new payer IDs, contract data, and payer-specific rules are correctly configured in Resolute. If mappings are off, claims can route to the wrong payer or be rejected outright, leading to delayed payments. Next, re-run eligibility to confirm that coverage, benefits, and any payer-specific eligibility rules reflect the new payer. This catches changes in benefit design or required authorizations that could affect patient responsibility or claim processing. Re-check pricing as well, because contracted rates and allowed amounts change with a new payer. Verifying pricing ensures the system applies the correct amounts and avoids under- or over-billing. Then run test claim submissions to validate the actual claim flow: from creation through submission to the payer system, ensuring no technical or data issues block processing. Verify 835/ERA postings to confirm that remittance advice aligns with what you expect under the new payer arrangement. This helps catch discrepancies between what was billed and what is remitted. Finally, inspect denials to identify any persistent issues stemming from mapping, pricing, or eligibility. Addressing denials early prevents revenue leakage and clarifies whether further configuration is needed. This approach is better than ignoring the switch, which risks widespread processing errors, or only re-running eligibility, which doesn’t test pricing, submission, or remittance. Starting over or canceling existing claims isn’t necessary and could disrupt ongoing revenue flow.

When a payer switch happens, the quickest effective health-check is to validate end-to-end compatibility with the new payer setup. Start by reviewing payer mappings to ensure the new payer IDs, contract data, and payer-specific rules are correctly configured in Resolute. If mappings are off, claims can route to the wrong payer or be rejected outright, leading to delayed payments.

Next, re-run eligibility to confirm that coverage, benefits, and any payer-specific eligibility rules reflect the new payer. This catches changes in benefit design or required authorizations that could affect patient responsibility or claim processing.

Re-check pricing as well, because contracted rates and allowed amounts change with a new payer. Verifying pricing ensures the system applies the correct amounts and avoids under- or over-billing.

Then run test claim submissions to validate the actual claim flow: from creation through submission to the payer system, ensuring no technical or data issues block processing.

Verify 835/ERA postings to confirm that remittance advice aligns with what you expect under the new payer arrangement. This helps catch discrepancies between what was billed and what is remitted.

Finally, inspect denials to identify any persistent issues stemming from mapping, pricing, or eligibility. Addressing denials early prevents revenue leakage and clarifies whether further configuration is needed.

This approach is better than ignoring the switch, which risks widespread processing errors, or only re-running eligibility, which doesn’t test pricing, submission, or remittance. Starting over or canceling existing claims isn’t necessary and could disrupt ongoing revenue flow.

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