Claims Dashboard
Monitor claims processing metrics, trends, and insights
Total Claims
1,864
+12% from last month
Approved
876
68.2% approval rate
Denied
245
19.1% denial rate
Pending Review
163
12.7% pending rate
Avg Processing Time
5.2 days
-0.8 days from last month
SLA Compliance
94.2%
+2.1% from last month
MTD Paid
$1.32M
68% of monthly budget
Current PEPM
$204.83
+5.0% vs budget
Claims Overview
View claims processing metrics and trends
Total Received
458
Total Processed
414
Processing Rate
90.4%
Approval Rate
73.2%
AI Insights
Automated analysis and recommendations
Potential Duplicate Claims
12 claims detected with similar CPT codes for the same patients within 30 days
Coding Optimization
32 claims could benefit from more specific ICD-10 codes based on documentation
High Denial Risk
8 claims flagged for missing documentation or authorization issues
Denial Rate Trend
Monthly denial rate vs. target
Top Denial Reasons
Percentage breakdown of denial reasons
Appeals & Reversals
Monthly appeal volume and upheld rate
Average Upheld Rate
69.4%
Average Resolution Time
14.2 days
Audit Findings
Quarterly audit exceptions and recovery
Total Exceptions
80
Total Recovery
$232,000
Recovery Rate
92.8%
Top Providers by Volume & Cost
Providers with highest claim volume and paid amounts
High-Cost Claimants
Members with claims exceeding $50,000
| ID | Amount | Plan | Condition |
|---|---|---|---|
| HCC-001 | $124,500 | PPO | Oncology |
| HCC-002 | $98,700 | PPO | Cardiac |
| HCC-003 | $87,600 | HMO | Transplant |
| HCC-004 | $76,500 | HDHP | Neonatal |
| HCC-005 | $65,400 | PPO | Orthopedic |
Total High-Cost Claims
18
Total Amount
$1.42M
Plan-Level Breakdown
Claims and costs by plan type
PMPM by Plan
PPO:$218.45
HMO:$176.82
HDHP:$152.64
Denial Rate by Plan
PPO:6.8%
HMO:8.2%
HDHP:5.4%