How to Submit a Medical Bill to a Clearinghouse - dummies

How to Submit a Medical Bill to a Clearinghouse

When you’re ready to submit your claim as a medical billing professional, you upload it to the clearinghouse to be sent to the payer. What, exactly, happens once your claim reaches the clearinghouse? Read on to find out.

How to check for errors

At the clearinghouse the claim is scrubbed, or checked for errors. Some errors identified by the clearinghouse can be corrected online so that the claim can be forwarded on. This type of error includes mistakes regarding revenue codes or other clerical issues. Other errors, however, are not so easily fixable. For these, the claim needs to be fixed at the provider’s office and then resubmitted.

Errors of this type include attempting to submit to a payer who is unknown to the clearinghouse. This situation can occur because some smaller payers don’t accept electronic claims and aren’t registered with any of the clearinghouse companies. In this case, you must submit a paper claim directly to the payer. (Directions for claim submission are always noted on the patient’s ID card.)

How to send the claim to the right payer

The clearinghouse directs the claim to the payer, according to the payer identification number, in a process known as payer matching.

During the provider’s original enrollment with the clearinghouse, payers are matched to the correct payer identification number following the first claim submission. The payer ID is the electronic address of the payer, and it tells the clearinghouse where to send the claim. Every time a claim is submitted to a new payer, the clearinghouse flags the claim for payer matching.

The provider is responsible for telling the clearinghouse which payer should receive the claim. If the provider identifies the wrong payer, the claim won’t be paid. (Payers don’t take claims that belong to other insurance companies and send them on. Instead, the payer usually rejects the claim and sends notice of that rejection to the submitting provider.)

The payer processes the claim and determines the reimbursement according to the codes submitted on the claim.

Revenue codes are not usually assigned by the coder, but they are programmed into the billing software and are based on the type of provider submitting the claim.

How to generate reports

Every clearinghouse keeps track of the claims that pass through its system. Reports are available that show sent claims, which payer they were sent to, and when all of these transactions occurred. Also available are reports that indicate when problems occur with claim submission. You can find these on the provider’s clearinghouse web page. Most payers send files back to the clearinghouse that report the status of the transmitted file(s).

Sometimes a provider submits an incorrect claim, isn’t notified of an error, and the claim just seems to disappear. This is why follow up is so important. Be sure to check the clearinghouse acceptance reports and verify them with the billing software submitted claims, also called the batch report, daily. If a claim is on the batch report but not on the acceptance report, find out why.

Daily verification of the rejected reports is also important. Part of your office routine should be to check the rejection report and fix all claims on the same day if possible. By following up immediately, you can prevent timely filing denials (that is, having your claim denied because you failed to submit it within the payer’s published timeframe).