Insurance coverage, visible at the point of care
One unified app for payer and policy management, eligibility verification, prior authorization, claims scrubbing and denial management, plus a patient portal, so billing teams stop chasing denials and clinicians know what is covered before they order care.
The problem
Insurance coverage is a clinical constraint that gets treated as a back-office afterthought. Services get delivered without pre-authorization, procedures exceed coverage limits, and claims are rejected for eligibility lapses that could have been caught at scheduling. Billing staff spend hours reworking and re-billing while clinicians have no visibility into whether the care they order will actually be paid for.
The solution
Healthcare Insurance Claims puts payer, policy, eligibility, prior-authorization and coverage-limit data in one place, and surfaces it right on the point-of-care request. Claims are scrubbed before submission, denials flow into a structured recovery queue, and administrators get analytics dashboards to track approval rates and aging by payer.
Everything revenue-cycle teams need in one app
Every capability below is implemented in the module.
Unified Payer & Policy Master
Manage payers with network type, payment terms and a default claim format, then attach per-patient policies with policy, group and member numbers in one screen.
Configurable Coverage Templates
Build coverage templates with deductible, out-of-pocket max and benefit-limit rules, broken down into per-department, per-service coverage lines.
Eligibility Verification
Verify a policy is active, pending or inactive with one click at scheduling or admission, catching lapsed coverage before a service is delivered.
Prior Authorization Workflow
Request, approve, deny or expire prior authorizations, with an authorization number generated automatically on approval.
Point-of-Care Coverage Visibility
Every service request shows a live coverage banner: percent covered, pre-authorization status, benefit-limit warnings and estimated patient cost.
Coverage-Limit & Benefit Alerts
Benefit usage is tracked automatically from paid claims, with a warning banner once a patient nears their policy maximum.
Claims Scrubbing & Denial-Risk Scoring
Claims are checked against eligibility, pre-authorization and line-level rules before submission, with a low, medium or high denial-risk score.
Denial Management & Rebilling
A structured denial queue tracks reason, amount and resolution, with one-click rebilling, appeal or write-off actions to recover revenue.
Claims Analytics & Patient Portal
Graph and pivot dashboards track approval rates, aging and denial trends by payer, while patients follow their own claims from a self-service portal.
How it works
Configure payers & coverage
Set up payers, network types and coverage templates with per-department, per-service coverage rules.
Verify eligibility & request pre-auth
Check policy eligibility at scheduling and submit prior-authorization requests for procedures that require approval.
Order care with coverage visible
Clinicians see real-time coverage percent, pre-auth status and benefit-limit warnings directly on the service request.
Submit, track & recover claims
Scrub claims before submission, monitor denial risk, and manage denials through a structured rebilling and appeal workflow.
Frequently asked
No sales fog. If your question isn't here, email us and we'll answer it the same way.
No. It is fully self-contained: patients and physicians are modeled with standard Contacts and Users, and invoicing is a light one-way bridge to Accounting.
Buy it on the Odoo App Store
Purchase, download and install directly from the official Odoo Apps Store — you'll always get the latest supported build.
Healthcare Insurance Claims
Payer and policy management, eligibility checks and prior authorization with coverage visible at the point of care — then claims scrubbing, denial-risk scoring and rebilling.
Buy on Odoo App Store