Improving the claims process for providers

Reducing administrative friction, improving efficiency and increasing transparency across the claims journey

The claims process, which includes the submission, review and payment of health care claims, helps ensure providers are paid accurately for covered services. The process is detailed to support accurate claims adjudication and payment, but it can also be inefficient and lead to unnecessary administrative burden for providers. For example, when providers need to follow up on the status of a claim, respond to requests for additional documentation or navigate appeals, they are shifting time and resources that could otherwise be devoted to patient care.

Further optimizing the claims process can provide greater transparency and simpler navigation, while innovative technology can reduce administrative friction. Together, these help providers get paid more efficiently and spend less time navigating paperwork and more on patient needs and outcomes.

Challenges and opportunities for improving the claims process

More than two-thirds of providers say that submitting "clean" claims (complete, accurate and error-free submissions) became more challenging in 2025 than it was the previous year, citing the growing need for a more consistent and streamlined claims experience. Ill-defined requirements, late documentation requests or unclear status updates can contribute to unnecessary burden for providers.

These challenges are also significant opportunities for transformation. In the Aetna^® Provider Survey, 41% of providers say that claims submission is a pain point that could be unlocked by technology. In fact, more than 30% of providers expect technology-enabled solutions to save them more than an hour each day.

To help address these issues, Aetna has been investing in digital tools that help support a more streamlined and consistent claims process. For example, the Aetna Claims Assist Manager (CAM) is an AI-powered agentic claims advisor platform that brings together eligibility, coverage, member and provider information to support claims decision-making, helping reduce processing time for complex claims that require manual review. As of May 2026, the technology has reduced processing time for complex claims requiring manual review by more than 20%. Aetna is also using provider feedback to help shape improvements across the entire claims experience.

Streamlining the claims process with three practical solutions can help providers get what they need sooner, so they can receive payment for covered services and devote time toward addressing patient needs.

Clarify documentation requirements upfront

When documentation is required to complete claim adjudication, providers benefit from knowing exactly what is needed and why.

Missing or inaccurate data remains a leading cause of claim denials and can contribute to rework, payment delays and additional administrative effort. Providers benefit from specific guidance on what information a claim needs to support adjudication. Based on provider feedback, Aetna is prioritizing changes that bring greater visibility earlier in the claims process, including enhancements to Electronic Remittance Advice (ERA) that give providers clearer guidance on what documentation is needed to keep a claim moving, as well as additional reason and remark codes to help reduce resubmissions and downstream issues.

When payers communicate these expectations consistently and earlier in the process, providers can respond more effectively and avoid unnecessary delays, saving time and resources for other responsibilities.

Strengthen contract implementation practices to improve payment accuracy

Getting payments right the first time helps reduce administrative effort for providers.

By continuing to strengthen contract-loading processes, defined turnaround expectations, and operational workflows, Aetna helps providers get accurate payments from day one and reduces the need for corrections and administrative rework. Automation tools, such as the Aetna Claims Assist Manager, can also bring efficiency to routine tasks, so providers get what they need sooner.

Give providers greater visibility into claim status

Visibility is most valuable when it helps providers understand not only where a claim stands, but what action is needed to keep it moving.

Real-time status tracking, standardized denial reason codes and clear guidance on next steps can enable providers to better manage claims while also helping patients navigate the process more confidently, with nearly three in four providers agreeing that payers' digital services help patients better understand their claims status. For providers treating Aetna members, the Availity provider portal provides centralized visibility into claims requiring additional information and the ability to submit attachments directly through the portal, reducing manual follow-up and simplifying document submission.

Enhancing the provider experience across the claims journey

When payers reduce administrative friction, clarify requirements and give providers better visibility throughout the claims journey, they create a more efficient and predictable process for everyone involved.

Using provider feedback to improve claims processes can strengthen coordination between payers and providers, easing operational strain so care teams can devote more time and resources to delivering quality care for the patients they serve.