Claims First Pass Resolution Rate

Benchmarking Report

Claims First Pass Resolution Rate

This PDF report includes benchmarking data (in a visual, chart-based format), an comprehensive KPI definition, characteristics of high performers and technical details on measuring Claims First Pass Resolution Rate. Purchase and download this easy-to-understand, presentation-ready report immediately to compare performance levels, set attainable performance targets, and push towards best-in-class performance for this KPI.


What is Claims First Pass Resolution Rate?

The total number of claims resolved on the initial submission (i.e., paid or transferred to patient responsibility) divided by the total number of claims adjudicated over the same period of time, as a percentage.

Why should Claims First Pass Resolution Rate be measured?

Claims First Pass Resolution Rate, or First Pass Resolve Rate, measures the percentage of claims paid or transferred to patient responsibility on initial submission to the insurance payer. Claims that are not resolved on the initial submission cause significant rework for both the health insurance payer and healthcare providers (e.g., doctors/practices, hospitals, healthcare systems, etc.). Poor inbound claims data (submitted by healthcare providers) is a common reason for claims rework. Missing claim information (e.g., no social security number, missing billing modifier, no plan code, etc.), duplicate claims submissions, and out-of-date submissions (i.e., claim not filed within required timeframe) can all trigger claims denials, causing significant rework on both ends (i.e., for the insurance company and healthcare provider). A high amount of rework in the claims process drives costs up, reduces employee productivity and negatively impacts customer experience.


Download a Sample Claims First Pass Resolution Rate

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