Claims Editor Software/Analysis Solutions


Performing retrospective claim analysis is a complex and time-consuming process. To reduce the complexity involved, SunStone’s proprietary software can assist you with ongoing maintenance of paid claims, highlighting opportunities for each service area. The goal of our retrospective claim analyses is to ensure you are obtaining accurate reimbursement for all services performed. Our software is a cost-effective solution that uses our real-world experience to ensure claim submission integrity and accurate reimbursement based on services rendered to patients. We offer this as a maintenance contract that allows you to submit data to SunStone for monthly review, so potential revenue opportunities can be identified and compliance enhanced.


Revenue opportunities are easily identified and compliance is enhanced. And the process is easy. You submit files to SunStone in the 835 format. We examine the thousands of billing and coding relationships contained in the file based on Current Procedural Terminology (“CPT”) and Healthcare Common Procedure Coding System (“HCPCS”) coding patterns. Our proprietary editor goes beyond the edits in Medicare’s Outpatient Code Editor (“OCE”) and Correct Coding Initiative (“CCI”) edits. This lets us identify opportunities for re-billing and/or compliance risks such as; claims missing potential additional HCPCS, add-on procedure without primary code, bundling errors, unit errors, and procedures reported without drugs or devices, to name a few.

The exception reports produced by our proprietary software provide items that require attention and are likely eligible for an adjustment claim.


Without question, the best way to ensure claim submission integrity and accurate reimbursement is to monitor outpatient paid claims on a routine basis. Doing this in a timely manner is a key to success. This is why our solution reviews outpatient paid claims on a timely and ongoing schedule. It is singularly focused on distilling significant amounts of data into actionable information that your staff can effectively address each month. Hospitals that adhere to a rigorous maintenance schedule have often funded the entire year’s program in just a few months.


This solution integrates with our Charge Description Master, Compliance, Revenue Cycle and Pricing Service Lines.


Timothy M. Mosco, M.S.
Vonda K. Moon, M.S.