Maximize the performance of claims management systems with the flexibility of FirstPass^™

FirstPass^™ is a rules-based software tool that applies generally-accepted and client-specific treatment and billing guidelines to both facility and professional medical claims, such as the CMS 1500 and UB04 hospital claims. By applying these guidelines to claims prior to entering the system, errors may be spotted or eliminated before they are populated in downstream applications.

FirstPass^™ is available as an application service provider (ASP) implementation or as an "in-house" server-based application. A software development kit (SDK) option provides the flexibility to write code and build applications around FirstPass^™.

The FirstPass^™ editing engine can be embedded into any claims management system without a change to the overall workflow. With the added strength of RuleWriter^™, payor-specific edits can be created to allow the claims management system to be completely customized. The result is a faster, more precise adjudication process that delivers an increase in claims auto adjudication and first-pass rates.

How does FirstPass^™ work?

FirstPass^™ allows health plans and payor organizations to check for all key clinical editing functions. These edits range from basic checks for accuracy of codes, appropriate use of modifiers, and validation of patient gender and age, to complex relationships such as instances of code fragmentation, utilization violations, mutually exclusive services, diagnosis/procedure relationships, and more. Nineteen edit categories utilizing nearly 200 edits, which encompass millions of service combinations, have been incorporated into FirstPass^™.

Private labeling

FirstPass^™ can be customized to assume the existing look and feel of the front-end interface users experience when they access the system, including logo placement and other graphical elements which help users identify fields and navigate their way through the claims management process.

Identifies common infractions

FirstPass^™ is able to automatically identify dozens of recognized clinical infractions:

• Unbundling-defined as the billing of a component service with its more comprehensive composite service.
• Rebundling-defined as the billing of multiple component codes, which can be described by a more comprehensive code.
• Service over-utilization-defined as the billing of a code beyond the appropriate numerical allowance.
• Inappropriate and unnecessary services-defined as the billing of code pairs or groups with other code pairs or groups considered medically inappropriate, such as mutually exclusive procedures like multiple E/M services on the same day.
• Modifier appropriateness-defined as billing modifiers before or after effective date or using in conjunction with an inappropriate procedure code.
• Procedure/diagnosis attributes-defined as billing an inappropriate procedure or diagnosis code for thepatient demographic or other code definition. Example: billing a female-only procedure for a male patient or billing cosmetic and experimental procedures.
• Procedure to diagnosis relationships-defined as the appropriateness of the diagnosis code(s) associated with a procedure. Example: billing an arthroscopy of the knee with a carpal tunnel diagnosis code.
• Code validity-defined as the billing of a procedure code before or after its effective date or use of a non-existent procedure code. Example: billing old office visit codes after 1999.
• Data integrity-defined as technical edits for correct dates, place of service codes, type of service codes, and others.