Getting paid starts long before a claim is sent. Registration, coding and charge entry all decide whether a claim is accepted the first time. This guide walks through the claim submission process in medical billing from the visit to the payer’s response, and shows where practices lose the most time.

Why the process matters

A claim that is rejected or denied has to be found, corrected and sent again. That delays payment and costs staff time. The best way to reduce that work is to treat healthcare claims submission as a series of checks, each one catching a different kind of error, instead of one task done at the end.

Step 1: Registration and eligibility

Collect the patient’s demographics and insurance details and confirm that the coverage is active. Errors here, such as a misspelled name or a wrong member ID, follow the claim all the way to the payer. Checking eligibility before the visit also tells you about copays, deductibles and authorization requirements.

Step 2: Documentation and coding

The provider documents the visit, and a coder turns it into procedure, diagnosis and modifier codes. The codes must match the documentation, and the diagnosis must support the service. Coding errors are among the most common reasons a claim is denied after it is processed.

Step 3: Charge entry

The coded services are entered as charges with the right provider, place of service, dates and units. Small mistakes here, such as a wrong date or unit count, are easy to miss and cause rejections later.

Step 4: Clean claim submission

A clean claim is one that has all the required information and no obvious errors, so it can be processed without questions. What counts as clean is set by each payer, so your checks should follow payer rules, not only your own.

Before sending, run a scrub, either through your billing system or a clearinghouse. A scrub checks for missing fields, invalid codes and combinations that payers do not accept. Fixing these before submission is far cheaper than fixing them afterward.

Professional claims use the CMS-1500 form, or the 837P in the electronic format. Institutional claims use the UB-04, or the 837I electronically. Most payers expect electronic claims.

Step 5: Claims submission, work edits and rejection reports

After you send a claim, the clearinghouse and the payer check it and send back acknowledgments. The 999 acknowledgment tells you whether the file was readable. The 277CA tells you, claim by claim, whether the payer accepted or rejected it before full processing.

Claims submission does not end when you click send. Someone needs to read these reports every day, because a rejected claim has not been processed at all and will not be paid until the error is corrected and the claim is sent again. Work the edits and rejections first, since they are usually quick fixes. Our guide on how to reduce claim rejections lists the most common causes and how to prevent them.

Step 6: Payer adjudication

The payer reviews the accepted claim against the patient’s coverage, the contract and its own policies, and then pays it, pays part of it or denies it. The result comes back as a remittance, which shows what was paid, what was adjusted and the reason codes for anything that was not paid.

Step 7: Payment posting and follow up

Post the payment and any patient balance, then check the remittance for adjustments you did not expect. Follow up on claims that have been waiting too long and on denials that can be corrected or appealed. Every payer has deadlines, so note them for each claim.

Where practices lose time

• Eligibility checked too late, or not at all.

• Coding and documentation that do not match.

• Claims sent without a scrub.

• Rejection reports that nobody reads for days.

• No record of why a claim was denied, so the same error returns.

Doing it in house or using claim submission services

Some practices keep every step in house. Others use claim submission services, which handle scrubbing, sending, tracking and rejection follow up for them. If you compare providers, ask how quickly they work rejections, how they report denials back to you and who owns the follow up when a payer does not respond.

Quick answers

What is the difference between a rejection and a denial?
A rejection is a claim refused before it is processed, usually because of a data error. A denial is a claim the payer processed and chose not to pay.

How often should we check for rejections?
Every business day. A rejected claim waits until someone corrects it.

Who sets the filing deadline?
Each payer sets its own, so track them by payer.

Next step

If many of your claims are rejected or denied, the cause is often in one or two steps of this process. Request a free claims audit and Practice Perfect Solutions and Services will show where claims are getting stuck and what it costs you.