Eligibility and referrals
Check the active plan, MCO, COB, provider enrollment, and referral or authorization dates before claim release. Flag stale referrals and missing identifiers before they enter an automatic submission batch.
Infectious diseases
HIV care crosses benefits. Billing must follow.
A drug, its administration, and the visit can follow different payment rules. Foresight distinguishes PrEP, HIV, and HCV requests, checks drug supply and benefit routes, and applies the clinic’s approved assistance and billing rules.
- PrEP and HIV treatment billed distinctly
- Drug supply matched to billed units
- Ryan White/ADAP requirements accounted for
What Foresight checks.
PrEP and HIV injectables
Match the documented indication, labs, medication history, and administered product to the correct benefit. Distinguish PrEP from HIV-treatment billing, and patient-supplied or pharmacy-billed medication from buy-and-bill stock. Keep ADAP and manufacturer assistance separate from the medical-visit billing decision.
HCV treatment requests
Assemble HCV RNA results, fibrosis assessment, prior-treatment history, and the medication record needed for the requested regimen. Match the packet to the payer's documentation requirements; route unresolved clinical questions to the prescriber.
Drug units and vaccines
Reconcile the administration record, inventory, product code, 11-digit NDC, unit of measure, and billable quantity. Check vaccine product and administration lines together, including state Medicaid/MCO edits. A package count is not necessarily the quantity a payer expects on the claim.
Ryan White and patient responsibility
Verify assistance eligibility and other coverage, then apply the clinic's approved patient-billing policy. Keep Ryan White payer-of-last-resort requirements, ADAP drug support, and any approved adjustments documented separately. Financial-assistance and write-off decisions stay with the clinic.
Denials, remittances, and deposits
Bring ERAs, paper EOBs, portal messages, and attachment requests into one queue. Distinguish corrected claims from appeals, assign an owner before filing deadlines, and match posted payments to deposits. Keep missing remittances and underpayments visible rather than leaving them in a month-end spreadsheet.
From intake to payment.
Coverage and assistance
Confirm eligibility, referrals, and assistance status before the encounter reaches billing.
Drug and service checks
Check indication, supply source, benefit route, NDC, and units against the clinical and inventory records.
Review and submission
Route uncertain clinical or billing findings to the responsible team. Every required PA receives clinician sign-off.
Payment reconciliation
Work denials across every source. Reconcile insurance payments, assistance, write-offs, patient balances, and deposits.