Insurance Claims & Approvals
Give your claims team a clearer path from approval to payment
NextHealth Care
NextHealth Care
Included in Care Clinics Pro and Care Hospitals; available as an add-on to Care Clinics.
NXH Care claims and approvals keeps the insurance workflow attached to the patient visit. Eligibility is checked where the payer’s service is connected, prior authorisations are tracked, and claims are built from the visit record in the format the payer’s gateway expects, then checked against payer rules before they leave. Submission, gateway acknowledgement, the payer’s decision and payment are recorded as separate statuses. A rejection arrives with its coded reason and can be corrected and resubmitted, appealed or written off.
Follow a claim from eligibility to payment
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Step 1
Check eligibility
Check eligibility where supported
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Step 2
Track approval
Follow the prior authorisation request
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Step 3
Prepare claim
Build from the visit and check payer rules
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Step 4
Submit
Send to the gateway and record the acknowledgement
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Step 5
Handle the decision
Review rejections, resubmit and track payment
What your team can do
- Check eligibility where the payer’s eligibility service is connected.
- Track prior authorisation requests and their responses.
- Build claims from the visit record in the format the payer’s gateway requires.
- Check claims against payer rules before submission.
- Record submission, acknowledgement, decision and payment as separate statuses.
- Record a rejection with its coded reason, then correct and resubmit, appeal or write it off.
Keep submission, acceptance and payment apart
A claim passes through stages that mean different things. Submitted means Care has sent it. Received means the gateway has acknowledged the file and returned a submission reference. A decision, approved, partly approved or rejected, comes from the payer, and paid comes from the remittance. Care records each stage as its own status, so a claim is never shown as accepted merely because it was sent.
Connections and prerequisites
Care builds claims for the Abu Dhabi (Shafafiya) and Dubai (eClaimLink) gateways, which share the DHPO transport. Live submission needs the facility’s gateway credentials and approved network access. Before that, the workflow runs against a sandbox that records a test acknowledgement. Payer eligibility checks run only where an insurer’s eligibility service has been connected for the installation. Submission to NPHIES in Saudi Arabia is not available. For each route and what it needs, see the interoperability scope.
Illustrative example: a rejected claim, corrected and resubmitted
This example uses synthetic data.
A claim for a synthetic patient, Lena Sample, is submitted through the gateway, which acknowledges it with a submission reference. The payer’s remittance later rejects one line and records a coded reason. The billing team opens the denial, corrects the coding and raises a resubmission. That creates a new draft claim linked to the original, with a resubmission type and a comment. They submit it, and the new claim is acknowledged in turn. The number of resubmissions is limited, and the payer still decides whether and when it pays.
Related NXH Care modules
3 more modules
Common questions
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Claims and approvals is included in Care Clinics Pro and Care Hospitals. It is not in the base Care Clinics plan, but it can be added to Care Clinics as an add-on.
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No. A real-time eligibility check runs only where the insurer’s eligibility service has been connected for the installation. Otherwise staff confirm eligibility as a step in the check-in checklist. Confirm the payers relevant to your facility during scoping.
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The rejection is recorded with its coded reason. The billing team then chooses to correct and resubmit, appeal or write the denial off, and a write-off needs a recorded note. A resubmission creates a new draft claim linked to the original.
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No. Care supports claim preparation, payer-rule checks and rejection handling. Claim acceptance and payment remain dependent on the payer and the submitted information.
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Care tracks prior authorisations and checks claims against payer rules and approvals. Review this sequence using a representative service and payer workflow.
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It shows that the gateway received the claim file and returned a submission reference. It does not mean the payer has accepted the claim or will pay it.
Not answered here? Contact the team
NXH Flow