Data capture from EOBs

Explanation of Benefits (EOBs)

Apart from carrying out data capture from Medical and Dental claims, we also carry out data capture from Medical claims with Explanation of Benefits (EOBs). EOBs can be of various types. Before capturing data from these EOBs, they need to be identified and classified into different categories. There are two types of EOBs, Medicare and Commercial. Before processing an EOB document, the SME checks validity of it by comparing various attributes like Date of Services, Procedure Code, Charges, Allowed Amount, Disallowed Amount, Deductible, Provider Paid, etc. between the EOB document and the Claim. If there is a mismatch in regards to any of these data, the EOB is declared invalid and sent back to the customer with associated reject reason. There are various reasons for rejection, such as missing information, contradictory information, multiple insurance carriers, etc.

After deciding the validity of the EOB, SMEs capture various attributes like Date of Services, Procedure Code, Charges, Allowed Amount, Disallowed Amount, Deductible, Provider Paid, etc. These attributes may be present under various different terms in EOBs raised from different Insurance Companies. The above listed terms can be found under different headings on the EOBs. It is a major challenge to locate and equate the terms given in the EOB with attributes like Allowed Amount, Disallowed Amount, Deductible Amount, etc. There can be up to 70 to 80 acceptable terms for one given attribute. We have developed a list of all these acceptable terms and made it available online to all the SMEs through Online Reference System (ORS). SMEs capture attributes given in the EOB using the list provided in the ORS. The major challenge in EOB processing is to locate and compare the verbiages given in the ORS and the EOB at the same time, comparing the value present under these verbiages with the accompanying claim.