Completeness
Check Member ID, active coverage, referral age, Ryan White/ADAP status, payer-of-last-resort path, lab support, medication route, patient-supplied flag, 11-digit NDC, UOM, quantity, vaccine admin line, and source denial document.
Infectious disease
HIV and infectious disease billing needs denial visibility before AR turns stale.
Foresight helps infectious disease clinics organize eligibility, Ryan White and uninsured handling, referrals, PrEP and HIV injectable workflows, vaccine coding, ERA/EOB reconciliation, and denials into one reviewable operating layer.
Coverage + NDC
Why it matters
In ID clinics, the same account can move through commercial insurance, Medicaid, Ryan White, Medicaid-pending, or self-pay logic. A claim can fail because a referral aged out, a product line lacks the 11-digit NDC, an injectable was patient-supplied, units were entered as one package instead of billable units, or a paper denial sat unseen.
Earlier denial detection
Cleaner specialty-drug and vaccine claims
Better Ryan White, uninsured, and reconciliation visibility
Workflow checks
Evidence to catch before work leaves the queue.
Operating workflow
Rules-first automation with human review where it counts.
- Eligibility, demographics, MCO, COB, referral age, Medicaid-pending status, Ryan White payer-of-last-resort rules, and uninsured write-off path
- PrEP and HIV injectable distinction: Apretude, Cabenuva, Sunlenca, and lenacapavir PrEP workflows routed by patient-supplied, pharmacy-billed, Ryan White/ADAP, or buy-and-bill status
- Drug/product codes and units, including examples such as J0739 for injectable PrEP cabotegravir, J0741 for Cabenuva, J1961 for lenacapavir treatment, and J0738/J0752 for lenacapavir PrEP when the benefit route supports billing those lines
- Vaccine product plus administration lines, 11-digit NDC, unit of measure, quantity, and state Medicaid/MCO adult vaccine administration rules
- ERA, paper EOB, portal denial, attachment request, and deposit reconciliation visibility
Run eligibility and referral checks early enough to stop automatic nightly claims from submitting with stale coverage.
Classify each medication event as patient-supplied, pharmacy-billed, clinic-stock, buy-and-bill, ADAP-supported, or Ryan White/uninsured before charge release.
Attach payer-required clinical evidence, labs, NDC, UOM, and units before submission for vaccines and injectables.
Normalize denials from clearinghouse, payer portal, ERA, paper mail, and EOB scans into one work queue.
Route write-offs, appeals, corrected claims, and payment mismatches with the responsible owner and source document attached.
Automation fit
Inspect the actual artifacts.
Foresight checks whether required evidence is present, whether records contradict each other, and whether the available facts look approvable under payer criteria before submission.
Contradictions
Flag PrEP versus HIV-treatment code mismatches, provider-owned drug billed when the medication was patient-supplied, ADAP or Ryan White support mixed into the wrong medical-visit billing path, stale referrals, or units copied from a package instead of billable units.
Payer approvability
Evaluate Medicare PrEP, Medicaid/MCO specialty-drug, vaccine administration, referral, medical-versus-pharmacy benefit, buy-and-bill, and attachment rules before claims or appeals age into timely-filing risk.
Common leakage points
The work Foresight is built to surface early.
Ryan White stored as a payer even though medical visits may need write-off logic rather than fee-for-service reimbursement
ADAP, manufacturer assistance, and Ryan White support mixed together without a clear medical-visit versus drug-benefit billing rule
Patient-supplied injectables accidentally billed as provider-owned medication
Maryland Medicaid or MCO vaccine/admin edits missed by generic charge templates
Referral older than one year or missing entirely
Paper-only denial discovery after timely filing pressure starts
Workflow risk audit
Map the risk surface.
A useful audit scores concrete workflow gaps: missing evidence, contradictory records, payer criteria risk, and follow-through after submission.
Required evidence present
Whether the claim, PA, or appeal has the basic identifiers and clinical anchors needed before work leaves the queue.
Chart contradictions
Where the EHR, notes, questionnaire, inventory, pharmacy response, and billing record point to different answers.
Payer approvability
Whether the available evidence appears to satisfy payer criteria before the submission creates AR or appeal work.
Follow-through
Whether approvals, denials, paper EOBs, portal messages, corrected claims, and deposits resolve cleanly after submission.
HIV / ID
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