Implementing Healthcare Claims Management with Salesforce Health Cloud

Escape Force
Published on
April 10, 2024

In the dynamic realm of healthcare, efficient management of healthcare claims stands as a pivotal aspect for both healthcare providers and patients alike. Accuracy in processing claims not only ensures timely reimbursement for providers but also contributes to a smoother patient experience. Salesforce Health Cloud emerges as a robust solution, offering tools and features to streamline the processing of both professional and institutional claims, while also emphasizing the importance of accurate coding for successful claims submission.

Understanding Healthcare Claims

Healthcare claims can be broadly categorized into two types: professional claims and institutional claims. Professional claims typically involve services rendered by individual healthcare providers such as physicians, therapists, or other licensed professionals. On the other hand, institutional claims pertain to services provided by healthcare facilities like hospitals, clinics, or nursing homes.

Begins with Eligibility Verification

It all begins with eligibility verification. Verification of benefits (VOB) is an important step in letting the patient know their benefits and limitations. Checking VOB periodically ensures data accuracy and informs the patient of any changes. This step significantly impacts claims accuracy, ensuring correct reimbursement.

Managing Professional Claims with Salesforce Health Cloud

Salesforce Health Cloud provides healthcare organizations with a comprehensive platform to manage professional claims efficiently. Its customizable interface allows for the creation of tailored workflows that align with the specific needs of each healthcare provider. Key features include:

1. **Claims Processing Automation:** Through Health Cloud we at Escape Force automated various aspects of professional claims processing, reducing manual errors and accelerating the reimbursement cycle. Through streamlined process flow we at Escape Force brought in relevant patient data that were seamlessly populated into claim forms, minimizing duplicate data entry.

2. **Procedure Code Accuracy with Modifiers:** Accurate procedure codes and modifiers are essential for describing the services provided by individual healthcare providers. Health Cloud facilitates the selection of appropriate codes and modifiers, ensuring compliance with billing regulations and maximizing reimbursement potential.

3. **Diagnostic Pointers:** Diagnostic pointers play a crucial role in linking diagnosis codes with procedures, ensuring medical necessity and justifying services rendered. Our implementation within Salesforce Health Cloud enables providers to include diagnostic pointers for each line of the claim, enhancing accuracy and minimizing denials.

4. **Patient Responsibility Calculation:** On Salesforce Health Cloud we at Escape Force implemented functionality to calculate patient responsibility accurately. By integrating with insurance eligibility verification systems, it determines the patient's coverage, co-pay, deductible, and coinsurance, enabling providers to generate an Explanation of Benefits (EOB) with the patient's responsibility clearly outlined.

Enhancing Institutional Claims Management

Institutional claims management presents its own set of challenges, particularly concerning revenue codes and detailed billing requirements. Salesforce Health Cloud offers robust functionalities to address these challenges effectively:

1. **Claims Processing Automation:** Through Salesforce Health Cloud we at Escape Force streamlined institutional claims management by automating various processes, reducing manual efforts, and improving efficiency. Integration with various systems ensures seamless data flow, minimizing errors and enhancing accuracy.

2. **Revenue Code Accuracy:** Accurate revenue codes classify the type of services provided by healthcare institutions, crucial for proper reimbursement. Health Cloud provides comprehensive libraries of revenue codes, facilitating accurate assignment based on services rendered, thus reducing payment delays.

3. **Compliance and Regulatory Support:** Through Salesforce Health Cloud we at Escape Force built-in compliance checks and regulatory updates, ensuring healthcare institutions adhere to billing guidelines and regulations, minimizing the risk of audits and penalties.

Importance of Accuracy in Healthcare Claims

The accuracy of procedure codes with modifiers, diagnostic pointers, revenue codes, and other coding elements is paramount for successful claims submission and reimbursement. Here's why accuracy matters:

1. **Maximized Reimbursement:** Accurate coding ensures that healthcare providers receive appropriate reimbursement, preventing revenue loss due to undercoding or denials.

2. **Compliance and Audit Preparedness:** Precise coding practices demonstrate compliance with billing regulations, reducing the likelihood of audits or investigations by regulatory bodies.

3. **Patient Experience:** Efficient claims processing translates to faster reimbursement, reducing financial strain on patients and enhancing their overall experience with healthcare providers.

Claims Dashboard

We at Escape Force also implemented the claims dashboard that gives comprehensive view of the claims and various stages of the process. This ensures the financial and billing team to get a high level view immediately, drill down to relevant data and can take corrective measures proactively.

Implementation by Escape Force

Escape Force has developed a comprehensive claims processing and management system within Salesforce Health Cloud. Our system provides sophisticated validation and submission processes. It validates claims before submission, identifying any missing or incorrect data, thus preventing erroneous submissions. Additionally, it listens to Electronic Remittance Advice (ERA) to track claim statuses and generates EOBs promptly, providing patients with clear information about their financial responsibility.


Effective management of healthcare claims is essential for financial sustainability and patient satisfaction in healthcare organizations. Salesforce Health Cloud offers a comprehensive platform to streamline both professional and institutional claims management processes, while emphasizing the importance of accurate coding for successful claims submission. By leveraging Health Cloud's capabilities, healthcare providers can optimize their revenue cycle management, minimize errors, deliver better outcomes for patients, and ensure timely generation of Explanation of Benefits (EOB) with patient responsibility information.

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