Claims First Pass Resolution Rate

Claims First Pass Resolution Rate

KPI Details

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(e.g., no social security number, missing billing modifier, no plan code, etc.), duplicate claims submissions, and out-of-date submissions (i.e., claim not filed within required timeframe) can all trigger claims denials, causing significant rework on both ends (i.e., for the insurance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.

KPI Definition

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.

KPI Calculation Instructions Claims First Pass Resolution Rate?

Two numbers are used to calculate this KPI: (1) the number of medical insurance claims resolved on the "first pass," and (2) the total number of medical claims adjudicated by the health insurance company over the same period of time. A medical claim resolved on the "first pass" should be considered any claim receiving a full or partial payment and/ or transferred to patient responsibility on the first initial claim submission (i.e., without need for subsequent data correction or resubmission). In the denominator for this calculation, do not include subsequent claims submissions following the initial submission (e.g., if a claims must be submitted twice to correct an error with the initial submission, count that only once in the denominator).

KPI Formula :

(Number of Medical Claims Resolved on Initial Submission / Total Number of Medical Claims Adjudicated) * 100