What Happens to Claims Once They Leave?

Once you have created an Invoice in the system you can instantly submit them to the clearinghouse. See Submit Electronic Claims for more information. After the clearinghouse receives your claims, they are scrubbed for errors at the clearinghouse level. A general check for errors can be done before your claim leaves the system. However, your clearinghouse can check for errors that are specific to your payers. If your claim has been rejected at the clearinghouse, it will not be forwarded to the payer.

Lifecycle of a Rejected Claim

1. Create invoice in the system
2. Submit claim to clearinghouse
3. Claim is scrubbed for errors at the clearinghouse
4. Check on your claim status with the clearinghouse
   • If claim is rejected at the clearinghouse, then
     • make necessary corrections to the claim in the system
     • Resubmit the claims to the clearinghouse

Some payers require you to complete EDI enrollment paperwork before they forward your claims electronically. Be sure to check with your clearinghouse to see if EDI enrollment is required by any of the payers you work with.

Lifecycle of a Successful Claim

1. Create invoice in the system
2. Submit claim to clearinghouse
3. Claim is scrubbed for errors at the clearinghouse
4. Check on your claim status with the clearinghouse
   • IF claim is not rejected in the clearinghouse, then
     • clearinghouse sends the claim to the payer
   • If your claim is denied, the payer will notify you either by a paper explanation of benefits (EOB) or electronic remittance advice (ERA).
     • Depending on the denial reason you can correct and resubmit the claims, or appeal. In some cases, a denial is expected, such as for a non-covered service. 
   • If your claim is paid, the payer will send you a notification of this either by EOB or ERA. They will pay you either by paper check or EFT, depending on what your agreement is with that payer. 

• Process Claim Payments ERA

Once you are receiving ERA's in the system, you post them to your Client's Ledger by following the tutorial above. 

Check out our Billing E-Book below to learn more about the Billing Process. 

• Billing E-Book