Medical Claims Processing

OnCourse helps streamline the front-end claims workflow far a Large Midwest based TPA.


The customers primary goal was to streamline the front end of both their EDI and Paper claims. The ability to perform Provider and Eligibility matching prior to loading claims into their system was essential to the project. Additionally, they wanted the ability to route claims to a number of trading partners prior to loading into their Claims software. A second initiative was to outsource their entire paper claims process including Mailroom, Scanning, Data Capture & Document Management Software. 


A proprietary OnCourse service called ValiData was implemented to perform Provider and Eligibility matching. Claims data is now run through a robust matching and validation process that significantly increases auto matching rates.

OnCourse provided a front-end solution for mailroom, sorting, scanning and data capture. This eased staffing / training issues and eliminated the need for scanning equipment. After the data capture is performed; the claims move through the same workflow as the EDI claims.

Scanned claims are uploaded to the FileBound Content Management Software; providing web access to the claims for internal and remote employees. 

Process Overview

  • EDI is routed to an OnCourse Secure FTP.
  • Claim mail is forwarded to OnCourse.
    • Mail is opened, sorted and scanned. 
    • Data Capture is performed and output in ANSI 837 5010 (EDI).
  • All claims are processed with ValiData prior to importing into Claims System.
  • Claim images are indexed and uploaded to FileBound. 


  • The front end process is simplified.
  • Turnaround times was significantly reduced. 
  • Scanning and Data Capture are consistently completed by the next business day. 
  • Pre-processing software increased matching and auto adjudication rates.
    • Clerical time was cut by 80% for managing “no match” claims.
  • FileBound enables access to the claim images from anywhere.
  • FileBound provides solutions for projects other than claims (W9’s, checks, etc.).


  • Reduced costs.
  • Labor savings and reduced training.
  • Productivity and efficiency is greatly improved.
  • No additional hardware or software development was required.