ClaimTrace User Guide

Chapter 1Welcome to ClaimTrace

ClaimTrace is a revenue assurance and payer-forensics platform for medical billing companies. It watches what happens to claims after they are submitted — and finds the money that quietly goes missing between submission and payment.

Your practice-management or EHR system creates and submits claims. ClaimTrace independently reconstructs everything that happens next. It ingests the same 837 claim files, 835 remittances, and clearinghouse acknowledgments your organization already produces, then:

rebuilds each claim's full lifecycle — submission, acknowledgment, status, adjudication, payment or denial;
compares what you submitted line by line against what the payer adjudicated;
detects suspected payer modifications — downcoding, dropped modifiers, unit reductions, unexpected bundling;
compares actual reimbursement to what your contracts say you should have been paid;
surfaces recurring payer behavior patterns across claims and clients;
assembles evidence packages for appeals and tracks every dollar recovered.

What ClaimTrace is not

ClaimTrace deliberately does not replace any part of your existing billing stack. It is not an EHR, a practice-management system, a scheduler, a clearinghouse, or a claim-entry application. It never creates, scrubs, or submits claims. EDI import is the normal way data enters the system; manual entry is the exception, never the workflow.

A note on languageClaimTrace is careful with words like "fraud." The engine reports suspected modifications and reimbursement discrepancies, always preserves alternative explanations, and requires an analyst to review and classify evidence before anything is treated as confirmed. Nothing is ever auto-labeled as misconduct.

Chapter 2How ClaimTrace is organized

Five ideas shape everything you will see in the application. Two minutes here will make every later chapter clearer.

Billing companies and clients

The top-level workspace is a billing company — your organization. Inside it are clients: the practices whose claims you manage (a family practice, a lab, an ambulance service). Every claim, remittance, finding, and report belongs to exactly one client within one billing company, and access is granted per user, per client.

The active client scope

Almost every screen shows data for one client at a time — the active client, chosen from the selector in the header bar. If a page seems empty or asks you to select a client, that is the reason: ClaimTrace never guesses which practice you mean, and never blends practices together by default.

Original files are immutable evidence

Every EDI file you import is preserved exactly as received, fingerprinted with a SHA-256 hash, and never modified. Everything else — claims, remittances, findings — is a projection derived from those originals, carrying full lineage back to the source file. If a file needs correcting, ClaimTrace saves your edit as a new revision and keeps the original untouched. This is what makes ClaimTrace's output usable as evidence: you can always show a payer, an attorney, or a regulator the untouched source.

Candidates become findings

The forensic engine works automatically and produces candidates — machine-detected discrepancies with a confidence score and preserved alternative explanations. A human analyst reviews candidates and promotes the ones that matter into findings, which then move through review, confirmation, appeal, and recovery. The machine detects; people decide.

Roles

Each user holds one or more roles in the billing company. Roles determine what a person can see and do; Chapter 19 lists them in full. A user can belong to more than one billing company and switches between them from the header.

Chapter 3Installing ClaimTrace

ClaimTrace installs on your own Windows computer or office server from a single signed installer. No cloud account is required, and your claim data never leaves your network.

Before you begin

A 64-bit Windows 10 or Windows 11 computer (or Windows Server) with administrator rights.
Roughly 2 GB of free disk space for the application and database, plus room for your EDI archives.
Your ClaimTrace license file (.clt), if you have purchased one. You can also install without a license and evaluate with sample data — see Chapter 4.

Running the installer

Run ClaimTraceSetup.exe. The installer is digitally signed by ExactEDI LLC — Windows will show the verified publisher on the elevation prompt.
Review and accept the license agreement.
On the License step, browse to your .clt license file if you have one, or continue without it to install in evaluation mode.
Choose the install type: Single computer keeps everything private to one machine; Office server makes ClaimTrace available to other computers in your office through their web browsers.
Confirm the install location and the separate data location — where your database, documents, and backups will live.
Click Install. The installer sets up the application, its database engine, and the ClaimTrace Windows service, then verifies that everything is healthy before finishing.

When the installer completes, a ClaimTrace shortcut appears on the desktop. Opening it launches ClaimTrace in your default browser. On an office-server install, coworkers open the address your administrator shares (for example http://billing-server:8080) — nothing needs to be installed on their machines.

UpdatesClaimTrace checks once a day for new versions and updated payer reason-code lists, and tells you in Company Settings when an update is ready. Nothing is installed without you running it. See Chapter 20.

Chapter 4First-run setup & evaluation mode

The first time ClaimTrace opens, a two-step wizard creates your billing company and your administrator account. It takes under a minute.

Setup wizard step 1: billing company legal and display name — **Step 1 — your billing company.** Enter your organization's legal name and the shorter display name that appears throughout the app.

Setup wizard step 2: administrator account — **Step 2 — the administrator account.** This first account is the billing company administrator. Passwords must be at least 12 characters.

Click Finish setup and ClaimTrace signs you straight in. There is no separate activation step.

Evaluation mode and the sample dataset

If ClaimTrace is installed without a license, it runs in evaluation mode: every feature works, but the system will not take in your organization's real claim files until a license is installed. So that you are not left staring at an empty screen, setup automatically installs a complete synthetic sample dataset:

a separate billing company called ClaimTrace Demo, with one client practice, Sunrise Family Care;
around 850 synthetic claims across fifteen months and six fictional payers, with matching remittances, denials, reversals, and acknowledgment files;
payer contracts at true contracted rates — so expected-versus-actual comparisons, forensic candidates, and findings all light up realistically.

The sample data is entirely synthetic — no real patients, providers, or payers — and lives in its own billing company, so it never mixes with your real work. When you no longer need it, an administrator can remove it in one action from Company Settings (Chapter 19).

Evaluation limitsIn evaluation mode a banner stays visible at the top of every page, new intake of real EDI is paused, and at most two user accounts can be created. Viewing, analysis, and export are never restricted. Installing a license lifts the limits immediately — no reinstall needed.

Chapter 5Signing in and your account

ClaimTrace sign-in page — **The sign-in page.** Enter the email address and password of your ClaimTrace account.

Forgot your password? There is deliberately no self-service reset: an administrator resets it from Users & Access, which issues you a temporary password. You will be asked to choose a new one at your next sign-in.
Account locked? After repeated failed attempts an account locks temporarily and the sign-in page says so plainly. Wait a few minutes and try again, or ask an administrator.
Changing your password. Click the key icon in the header at any time to choose a new password (12–128 characters).

Choosing a billing company

If you belong to more than one billing company — for example your own organization plus the ClaimTrace Demo company — you will see a chooser after signing in, and a Switch link in the header thereafter.

Select a billing company page with membership cards — **Select a billing company.** Each card shows your roles in that company. Click **Enter** to work in it; you can switch at any time without signing out.

Chapter 6Finding your way around

Every page shares the same frame: navigation on the left, scope and account controls in the header, and your working area in the middle.

The header

Billing company — the workspace you are in, with a Switch link if you belong to more than one.
Active client — the practice whose data you are viewing. Click it to switch practices or clear the scope. Most screens require an active client.
Your account — avatar, change-password (key icon), and sign out.

The sidebar

Section	Pages	What it's for
Overview	Overview	The revenue-intelligence dashboard (Ch. 7)
Intelligence	Findings · Payer Patterns · Payer Forensics	Detection results and analyst review (Ch. 14–16)
Claims	Claims · Claim Chain Explorer · EDI Intake · Remittances · Acknowledgments · Patients	Your data and its lifecycle (Ch. 8–12)
Recovery	Appeals · Recoveries	Appeal packages and recovered dollars (Ch. 17–18)
Administration	Clients · Contracts & Fee Schedules · Users & Access · Company Settings	Configuration and people (Ch. 13, 19, 20)

Items you do not have permission to use fail safely — the page tells you plainly rather than showing partial data.

Banners

License and evaluation notices appear as a banner above the working area (for example, "ClaimTrace is running in evaluation mode with sample data"), always with a link to the license details in Company Settings.

Chapter 7The Overview dashboard

Overview is the executive answer to "where is our money at risk, and is it coming back?" — every number on it drills down to the underlying evidence.

Overview dashboard with KPI row and revenue leakage trend — **Overview.** The KPI row summarizes the active client's position; every tile explains its own definition via the ⓘ icon — numerator, date basis, inclusions and exclusions.

Tile	What it measures
Potential Revenue at Risk	Detected variance not yet reviewed or confirmed — the size of the open question.
Confirmed Underpayments	Variance an analyst has reviewed and confirmed as owed.
Suspected Modifications	Claims with machine-detected, analyst-unresolved payer modifications.
Appeal-Ready Value	Confirmed findings packaged or recommended for appeal.
Recovered Revenue	Dollars validated as actually recovered (Ch. 18).

Below the KPI row sit the working panels — scroll the page to see them all:

Revenue Leakage Trend — detected, confirmed, and recovered variance over time (daily, weekly, or monthly).
Findings by Type and the Payer Risk Matrix — where the problems concentrate, by classification and by payer.
Priority Findings Queue — the highest-value open items, with deadlines and owners.
Appeal Pipeline and Recovery by Payer — how appeals are progressing and where recoveries come from.

Full-length overview dashboard — **The full page.** Use the **Filters** control to narrow every panel at once by date range or payer; a "Filtered view" banner reminds you a filter is active.

Chapter 8Bringing data in: EDI Intake

EDI Intake is the front door for data. Files arrive three ways: automatic clearinghouse sync, integrations, or drag-and-drop upload — and every file is preserved immutably from the moment it lands.

EDI Intake page with sync panels, upload zone and file table — **EDI Intake.** Clearinghouse connections at the top, the upload zone beneath, and the file ledger with per-file status and diagnostics.

What you can import

ClaimTrace accepts the standard X12 transaction set produced by your billing workflow — 837P claims, 835 remittances, 999 and 277CA acknowledgments, and 276/277 claim status — up to 25 MB per file. Drop files onto the upload zone or click it to browse.

File statuses

Status	Meaning
Queued / Processing	Received and waiting for, or undergoing, validation and projection.
Validated	Parsed cleanly; its claims, remittances, or acknowledgments are now in the system.
ValidationFailed	The file has structural problems. Expand the row to see line-level diagnostics.
Duplicate	Byte-identical to a file already imported; nothing is double-counted.
Unsupported	A transaction type ClaimTrace recognizes but does not process.

Fixing a broken file

Expand a failed file and choose Inspect & edit. A highlighted X12 editor opens showing exactly which segments the validator flagged. Correct the content, Validate, and Save as revision — your correction is stored as a new revision and reprocessed, while the original file remains untouched as evidence.

Clearinghouse auto-sync

Instead of uploading by hand, connect ClaimTrace to the places files already accumulate. Presets exist for common clearinghouses (API and SFTP) and for a simple watched folder. Each connection shows its last sync, can be tested, paused, or run on demand with Sync now, and keeps a run history: files discovered, imported, and skipped on every pass.

Duplicates are freeAuto-sync and manual upload can safely overlap. ClaimTrace fingerprints every file, so re-delivering the same file never creates duplicate claims.

Chapter 9Claims and patient profiles

The Claims list is the canonical record of what was submitted; each claim page shows what came back and how the two compare.

Claims list with search and status column — **Claims.** Search by claim number or patient. The Status column tracks the submission itself: Imported, Corrected, Replaced, or Voided. There is deliberately no "new claim" button — claims enter through EDI.

Claim detail with service lines, adjudication and timeline — **A claim.** Service lines show charge and payment per line — with an "adjudicated as" flag wherever the payer paid against a different code than was submitted. Below: the adjudication summary, the claim's timeline with links to its source files, and any findings raised on this claim.

Patient billing profiles

Use the data-quality and coverage filters to find profiles needing attention — for example patients whose files show conflicting demographics or no coverage on file — and export the filtered list to CSV.

Chapter 10Acknowledgments & status

The Acknowledgments page correlates 999, 277CA, and 277 responses with your claims, so you can see what the clearinghouse and payer have said about each submission.

Acknowledgments page with history and review queues — **Acknowledgments.** The History tab lists every acknowledgment file and its results; Review queues collects items ClaimTrace could not match automatically.

When an acknowledgment cannot be tied to a claim with confidence — an unmatched reference, an ambiguous match, a duplicate — it lands in a review queue instead of being silently guessed. Open the item, confirm or reassign the match, and record a reason; the resolution is kept permanently.

Administrative status onlyAcknowledgments prove a file was received and accepted for processing — never that a claim was adjudicated or paid. Payment truth comes from the 835 remittance (Chapter 11).

Chapter 11Remittances

Every 835 you import becomes a remittance batch: the payment, its claims, and how each adjudicated line matched back to what you submitted.

Remittances list with KPIs and filters — **Remittances.** Batches by EFT or check number, with payer, method, amount, and whether the batch is balanced — the payment equals the sum of its parts.

Remittance detail with matching tabs — **A remittance.** The summary reconciles the payment; the tabs separate **exact matches**, **partial matches**, and **unmatched** lines. Partial and unmatched lines are where discrepancies hide — the forensic engine reads these the same way you do.

Each line shows the adjudicated code beside the submitted code, paid amounts, and CARC/RARC adjustment codes with their plain-language descriptions. Download the original 835 or view it inline at any time — the source file is one click away from every derived number.

Out-of-order arrivalsIf an 835 arrives before its 837 (it happens), ClaimTrace holds it and matches it retroactively when the claim appears. Nothing is lost to timing.

Chapter 12The Claim Chain Explorer

The Claim Chain Explorer answers "what exactly happened to this claim?" — one claim, its complete story, on one screen. It is where most investigations start and end.

Claim Chain Explorer journey tab — **Journey.** The claim's life in order: source file, claim, acknowledgments, status responses, and remittance — each event linked to its source evidence.

Claim Chain Explorer financials tab — **Financials.** The claim's money story: submitted charges, expected allowed (from your contract), actual allowed, paid, patient responsibility, potential and confirmed variance, recovered, and the outstanding opportunity — with the basis for each number stated.

Claim Chain Explorer comparisons tab — **Comparisons.** Submitted versus adjudicated, line by line. ClaimTrace distinguishes "changed by payer (evidence returned)" from "difference inferred — analyst review required" — the distinction that keeps your appeals honest.

The fourth tab, Evidence, is the claim's evidence index: every source file with its SHA-256 fingerprint and every projection version. From the header you can Export chain as JSON or generate an evidence package (Chapter 17).

Chapter 13Contracts & fee schedules

Contracts are what turn "the payer paid less" into "the payer paid less than they agreed to." Loading your fee schedules unlocks expected-reimbursement comparisons everywhere.

Contracts page with payer contract and fee schedule rules — **Contracts & Fee Schedules.** One participation agreement per payer, each with its status chip and its fee schedules. The sample dataset arrives with six payer contracts already active — which is why its variances are quantified from the start.

Click New contract, pick the payer (ClaimTrace suggests payers it has actually observed in your data), name it, and set the effective date. The contract starts as a draft.
Add a fee schedule and import rates from CSV — Preview CSV first to see exactly how rows will be interpreted; import errors are listed row by row.
Review the rules table (code, modifiers, place of service, rate, effective window), then Approve the schedule and the contract.

Only approved contracts participate in expected-reimbursement calculations. Rates can be flat amounts, percent-of-charge, or multiple-procedure (MPPR) rules, and every rule records its rounding and tolerance so calculations are reproducible.

Chapter 14Payer Forensics

The forensic engine runs automatically as remittances arrive, comparing adjudication against submission and contract. Its output is a queue of candidates — each one a specific, evidence-backed question for an analyst.

Payer Forensics candidate list — **Payer Forensics.** Each candidate names its classification (downcoding, modifier discrepancy, unit reduction, contract variance…), the submitted→adjudicated change, the dollar variance, a confidence score, and the exact detection rule and version that fired.

Forensic candidate detail with evidence and promote action — **A candidate.** The full comparison, the matched remittance, the rule's evidence strength, alternative explanations the engine itself preserved, and the evidence hash. If it deserves human follow-up, click **Promote to finding**.

The bottom of the page documents every detection rule in plain language, including its preconditions — so you always know why something was (or wasn't) flagged. Rules are versioned; a candidate permanently records which rule version produced it.

Why candidates aren't findingsA candidate is the machine's observation, frozen with its evidence. Promotion creates a finding — the analyst-owned record that moves through review and appeal. This separation is what lets you stand behind every accusation with a straight face.

Chapter 15Reviewing findings

Findings are the analyst's workbench: every suspected discrepancy that merits human judgment, moving through a disciplined, fully recorded review lifecycle.

Findings queue — **Findings.** Work from queues — New, High value, Deadline risk, Evidence needed, Confirmed, Appeal recommended — rather than one long list. Each row carries severity, classification, dollar variance, and the finding's evidence tier.

Finding detail with automated and analyst conclusions — **A finding.** The **automated conclusion is immutable** — what the engine said, preserved forever. Your **analyst conclusion** sits beside it and evolves as you work. Every action requires a rationale, and the review history below is append-only.

The review flow

Start review on a finding from a queue.
Examine the evidence — the claim, the remittance lines, the contract rate, the alternative explanations. Jump to the Claim Chain Explorer whenever you need the full story.
If evidence is thin, Request evidence or Raise the evidence tier (tiers run 1–5) as documentation accumulates.
Confirm the finding, Reclassify it, or Dismiss it — always with a written rationale, which is preserved permanently.
Confirmed findings worth pursuing get Recommend appeal, then Mark package ready when the evidence is assembled (Chapter 17).

Each finding also shows a predicted appeal outcome — a statistical estimate based on comparable findings, shown with its base rate and the factors that moved the score. It is decision support, not evidence, and the page says so.

Chapter 16Payer pattern intelligence

One underpaid claim is a mistake. Three hundred underpaid claims that all share a payer, a code, and an 8% haircut is a pattern — and patterns are leverage.

Payer patterns page with alerts and impact chart — **Payer Patterns.** Recurring payer behaviors ranked by potential impact, with priority alerts for high-dollar concentrations, threshold breaches, and behaviors recurring across multiple clients.

Click Recompute patterns after significant new data arrives, filter by payer, time window, or confidence, and open any pattern to see its full statistical documentation: the method, inputs, assumptions, thresholds, result, and — importantly — its stated limitations. Every claim that participates in the pattern is listed as evidence.

A pattern can be exported directly as an evidence package tailored for a regulator or attorney audience — the cross-claim counterpart of the per-claim packages in Chapter 17.

Chapter 17Appeals & evidence packages

When a finding is worth fighting, ClaimTrace assembles the fight for you: a versioned, tamper-evident package of documents and original EDI exhibits, and a tracked appeal lifecycle from drafting to decision.

The Appeals page lists each appeal with its type and level, filing deadline, dollar amount at issue, and current status through to the payer's decision. Appeals appear here as confirmed findings are recommended for appeal and their packages marked ready (Chapter 15).

Evidence packages

From an appeal (or a claim chain, or a pattern), generate an evidence package: a ZIP containing the assembled documents, the relevant original EDI files as exhibits, and a manifest of SHA-256 hashes that lets any recipient verify nothing was altered. Packages are versioned and immutable — regenerating after new evidence produces a new version, and every version remains downloadable with its template version and approval state.

Packages are tailored to their audience: a payer appeal package reads differently from one prepared for a regulator or an attorney.

The appeal lifecycle

Appeals move through explicit stages — review, documentation, drafting, ready, approved, submitted, acknowledged, pending decision — to a recorded outcome of approved, partially approved, or denied, including the real submission method and confirmation number. The dashboard's Appeal Pipeline (Chapter 7) totals this flow, and decided appeals feed the recovery ledger (Chapter 18) and the outcome predictions (Chapter 15).

Chapter 18Recovery tracking

Recovery is where claimed victories become validated dollars. ClaimTrace insists on the difference.

The Recoveries page opens with a metrics strip — validated recovery dollars, the validated-to-detected ratio, reversals, average days to recovery, and appeal success rate — above the ledger of individual recoveries.

When payment arrives following an appeal, the recovery starts as Needs validation. An analyst confirms the money actually landed against the right claim and marks it Validated — or Rejected, or later Reversed if the payer claws it back. Each transition records a rationale, permanently. Only validated recoveries count in the dashboard's Recovered Revenue.

Chapter 19Managing clients, users & settings

Clients

Client detail page with locations, providers and assignments — **A client.** Manage locations, providers, an optional logo, and — critically — **assignments**: which of your staff can work in this client, with full or read-only access.

Client access is deliberate: a user sees a practice's data only if assigned to that practice. The client page is also where a practice can be suspended, reactivated, or excluded from pooled analytics, each with a recorded reason.

Users & Access

Users and access page with memberships and roles — **Users & Access.** Create accounts with a temporary password, toggle roles, reset passwords, and deactivate users. ClaimTrace will not let you deactivate the last active administrator.

Role	Intended for
Billing Company Administrator	Full administration: users, clients, settings, license.
Billing Manager	Day-to-day operational oversight across the company.
Forensic Analyst	Working the forensics queue and findings review.
Payment Integrity Analyst	Contract variance and expected-reimbursement work.
Appeals Specialist	Assembling packages and running the appeal lifecycle.
Revenue Analyst	Dashboards, patterns, and reporting.
Auditor	Read access plus the audit trail.
Read Only	Viewing without any write actions.

Company Settings

Company Settings. Company profile (names, time zone, currency), the license card, software updates, sample-data management, and recent audit events.

The Sample data card installs or removes the ClaimTrace Demo dataset described in Chapter 4 — removal shows exactly what will be purged and asks for confirmation. The Recent audit events card shows who did what, when; every administrative action in ClaimTrace is audited.

Chapter 20Licensing & software updates

Installing your license

Open Company Settings → License.
Open your .clt license file in a text editor and paste its contents into the license box.
Click Install license. The card immediately shows your organization name, seat count, and expiry.

Licenses are verified offline — no internet connection or activation server is involved. The license states you may see:

State	What it means
Licensed	Everything is normal.
Expiring soon	Renewal is approaching; nothing is restricted yet.
Grace period	The license expired recently; ClaimTrace keeps working while you renew.
Expired / Unlicensed	New EDI intake pauses. Your data is never locked: viewing, analysis, and export always work.

Software updates

The Software updates card in Company Settings shows the installed version and checks daily (or on demand with Check now) for new releases and updated CARC/RARC reason-code lists. When an update is available you get its release notes, a download link, and the installer's SHA-256 checksum. Run the downloaded installer on the ClaimTrace machine — settings and data are preserved, and the update completes in place.

Chapter 21Troubleshooting

Symptom	Likely cause & fix
A page says "Select an active client first"	Most screens are client-scoped. Pick a practice from the client selector in the header.
Sign-in says the account is locked	Too many failed attempts. Wait a few minutes, or have an administrator reset the password in Users & Access.
An uploaded file shows Duplicate	The identical file was already imported. Nothing to fix — data is never double-counted.
A file shows ValidationFailed	Expand the row for segment-level diagnostics; use Inspect & edit to correct and save a revision.
A remittance shows Imbalanced	The 835's stated payment doesn't equal the sum of its detail. Review the batch summary — this is worth a look, not an error in ClaimTrace.
The evaluation banner won't go away	No valid license is installed. See Chapter 20 — the banner clears the moment a license is accepted.
Numbers seem stale after a big import	Projections and analytics run in the background; large imports can take a few minutes to fully settle. Refresh the page.
You see "You do not have access to this resource"	Your roles or client assignments don't cover it. Ask your administrator — access is granted per client, per role.

Chapter 22Glossary

Term	Definition
837P	The X12 professional claim transaction — what your billing system submits.
835	The electronic remittance advice (ERA) — the payer's statement of what it adjudicated and paid.
999 / 277CA	Acknowledgments: file-level acceptance (999) and claim-level clearinghouse acknowledgment (277CA).
276 / 277	Claim status request and response transactions.
CARC / RARC	Claim Adjustment Reason Codes and Remittance Advice Remark Codes — the payer's stated reasons for adjustments.
Candidate	A machine-detected discrepancy awaiting analyst attention (Payer Forensics).
Finding	An analyst-owned discrepancy record moving through review, appeal, and recovery.
Evidence tier	A 1–5 rating of how well-documented a finding is.
Evidence package	A versioned ZIP of documents and original EDI exhibits with a hash manifest proving integrity.
Downcoding	A payer adjudicating a service at a lower-valued code than was submitted.
MPPR	Multiple Procedure Payment Reduction — reduced rates for subsequent procedures on the same date.
Expected reimbursement	What an approved contract says a line should have allowed/paid.
Variance	The dollar difference between expected and actual reimbursement.
Active client	The practice whose data the current screen shows, chosen in the header.
Evaluation mode	The unlicensed state: full functionality on sample data, new real intake paused.