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> Processing EOBs for Payers and Providers

1 Health Plan Insurance EOB to 835 Conversion

Health Plans (Payers) have a HIPAA mandate to send remittance information in the ANSI 835 format to their provider customers, presenting significant challenges for Payer’s legacy systems, codes and business practices.  Despite these challenges, Providers are demanding ANSI-compliant electronic files with full sets of customized HIPAA CARC/RARC codes.  Complicating matters, states Attorneys General are increasingly viewing non-compliance with HIPAA information standards as a reason for regulatory enforcement action.  RevenueExpress for Payers is designed to make Payers instantly HIPAA compliant, and fully addresses these problems.

Legacy systems are expensive to change, especially with burgeoning code designations and the addition of new transaction types. What’s often missed is that both the Payer and the Provider own “legacy” systems, and each side has their own priorities and preferences for enhancements. Updating legacy systems on one side of the remittance equation, at the Payer side for example, would be totally ineffective since it leaves the Provider side of the problem completely unaddressed.  Providers need to do be able to actively examine and post each incoming payment in real time.  For Providers to be able to do that, Payers need to provide all denial information in a manner that the Provider system can understand.  Systems don’t need to be changed- just customized in a comprehensive manner.

Sound impossible?  It’s not- RevenueExpress for Payers does exactly that.

With tight budgets and lots of high priority projects it is impossible to get everything done. As a consequence a substantial majority of commercial health plans are sending paper based Explanation of Benefit (EOB) forms by mail along with the check for payment. This is very expensive for all concerned. For the Payers the costs associated with print and mail operations are high and rising, and Provider dissatisfaction with paper EOB’s is getting louder all the time.  It’s only a matter of time before increasing regulatory force is brought to bear on Payers to meet the Providers' expressed needs.  For Providers, extracting data from the EOB manually or with an inefficient and error prone manual solution is both costly and ineffective.  No Provider in the nation has independently figured out a way to cost effectively address every denial, and most Providers only examine a small statistical sample of incoming remittances for audit purposes. 

RevenueExpress for Payers addresses these challenges head-on, and offers any easy and fast way for Payers and Providers to communicate electronically while significantly lowering everyone’s costs. Truly a win-win situation.

Using RevenueExpress for Payers is easy and Payers do not need to convert any legacy computer systems, do not need to change any print stream file formats, and do not need to adopt any one-size-fits-all HIPAA solution. RevenueExpress for Payers accepts existing files, balances the claims to the service line level, and converts Payer legacy codes to CARC/RARC codes in a format designed especially for each individual Provider according to their own individual preferences. If the 837 information is available, you can even deliver Providers a helpful comparison for Denial Management purposes.  The accompanying check can also be deposited (via Check 21) into the provider account!

RevenueExpress for Payers is unique in the industry, as it is capable of dealing with any Payers print file as-is. No custom coding is required, once the product is set up and ready to operate. If you change your output files, RevenueExpress for Payers can change right along with you. If you add new codes, or change existing codes, RevenueExpress for Payers can instantly be updated in accordance with your Provider preferences. Your print and mail costs can be dramatically reduced. You can achieve instant HIPAA compliance. Providers get the data in any way they choose.

Features and Benefits

  • No need to make costly updates to legacy systems
  • Helps avoid regulatory enforcement costs
  • Significantly lower costs to send EOB information to providers
  • Reduced volume of customer service calls from providers
  • Rapid and easy HIPAA compliance
  • Improved provider relations

2 Provider Side EOB to 835 Conversion

RevenueExpress for Providers is a new healthcare solution that can be your catalyst for significant increases in provider cash flow and revenue with lower costs. By equipping your revenue cycle staff with a complete data set from the EOB in 835 format, with reason codes that your system understands, and a complete transaction reconciled and balanced at the service line level and associated with the payment, they can perform accurate and timely rebilling and denial management and achieve these important goals. When integrated with RemitTrac® our complete lockbox platform, it can also process patient payments at all your points of encounter, similarly maximizing revenue and accelerating cash flow for your organization.

> Overview

While there have been numerous initiatives to digitize all healthcare information, progress has been slow overall. Despite the fact that the ANSI 835 Electronic Remittance Advice has been widely adopted as the payment and remittance information mechanism for Medicare and Medicaid, two well known consulting firms estimate that more than 60% of the 3.5 Billion claims annually are still settled on paper, and that this paper mountain is not going away any time soon. Without accurate and highly automated solutions for creating a complete data set in 835 format, providers have been forced to resort to manual keying of data or the use of simple OCR data lift solutions which lack many essential features and provide inadequate output. In addition consumer directed healthcare, with higher deductibles and co-pays along with the advent of Health Savings Accounts is significantly increasing the patient responsibility component of healthcare revenue.

Paper EOB Challenges

The volume of paper EOB forms received every day, along with accompanying checks, which may come together in the same mailing or be sent at different times or to different places, is often overwhelming and certainly costly. Many providers may already use a bank lockbox to process these deposits and receive highly summarized posting data. Paper copies or images of the EOBs are then sent back to their business office to decipher, so that they can figure out the next steps to be taken. Without access to the full and validated data on the EOB there is no way of knowing why certain claim payments were denied, or what action needs to be taken next. Do you bill the patient for a deductible, and if so for how much? Is there a secondary payer involved? How was a non-allowed deduction applied? The answers to all these questions are needed before it is possible to collect amounts propely due for services rendered, and the critical data required is usually somewhere on the EOB. With margins on the provision of care so low the opportunity to capture significant additional revenue is crucial and must not be squandered.

Existing EOB Solution deficiciencies

  • Banks are offering mostly just a cash posting file from their lockbox services containing minimal data even though it may be in 835 format
  • Most OCR data lift solutions only address a small part of the need because they do not have:
    1. -Data validation
    2. -Service line level balancing
    3. -Reconciliation, balancing and reassociation with the payment
    4. -A full spectrum payments capability
    5. -Reason Code cross walk tables
  • Data capture by simply keying from image is often is not cost effective even with offshore labor and has issues similar to OCR data lift


Fortunately with RevenueExpress for Providers ImageScan will help you address these glaring deficiencies today, with proven, easy to implement technology. With ImageScan’s 17 years experience in large bank lockbox processing and the recently enhanced RevenueExpress for Providers EOB to 835 conversion service, you can take advanctage of an integrated solution set that will allow you to process patient and other payments, and convert EOBs from paper, pdfs, print streams or scanned images into complete electronic payment data in 835 format. By collecting patient payments conveniently and efficiently at point of service, using the Remote Lockbox and Check 21 modules of RemitTrac and using RevenuExpress to provide the right data set for re-billing and denial management, more revenue will be collected with lower operations costs.

RevenueExpress for Providers is offered as a service through one of ImageScan’s Channel Partners and participating Banks. All you need to do is to provide images of the EOB, either by obtaining them from your bank or scanning them on an inexpensive desktop scanner. We will do the rest. Patient payments can be scanned in your offices if they do not already go to a lockbox and the check images (under Check 21) sent to the bank for deposit into your regular account. There is no need to change any banking relationships. To find out how we can help you visit our website or call (see below).

RemitTrac® and RevenueExpress® for Provider -Benefits

  • Much higher quality and more complete data in the 835
  • Accelerated cash availability
  • Automated reason code interpretation for re-billing and denial management
  • Lower labor and processing costs
  • Retains existing banking relationships
  • Full reconciliation and balancing of claim at the service line level
  • Re-association and balancing to any payments already deposited at your bank
  • Parsed EOB claim images for each patient can be imported to electronic health record for efficient HIPAA PHI compliance
  • Imports scanned images from lockbox or other existing workflow processes
  • Handles patient payments at point of encounter with associated registration documents

RemitTrac® and RevenueExpress® -Features

  • High speed OCR provides accurate data capture and minimizes manual data entry.
  • Paper is converted into the electronic ANSI standard 835 Remittance Advice which can easily be posted to most accounts receivable systems.
  • Solutions can be configured for a wide variety of EOB processing volumes
  • Document Image data can be used for patient records and files
  • Solution is HIPAA Compliant
  • All data entry can be done cost effectively on-shore because of the efficiency of the system
  • Payment information can be submitted in Check 21 compliant form to the paying bank for faster funds availability
  • Documents and payments can be captured at remote sites such as physician offices or clinics
  • 837 Claims data can be displayed alongside EOB to add missing data and speed up re-billing

If you have a challenge processing paper EOBs in an efficient and timely manner and would like more information on RevenueExpress please contact us or click here for more information. See also the press release below that describes one of the ways that we can handle your healthcare payment transactions.

ImageScan's RemitTrac® helps Bank of New York win Humana account