Creating Claims

Once all patient, provider, and encounter information has been entered into the practice management software, an electronic claim can be created.

This can be done individually or as a batch of claims. Once created these are transmitted or uploaded to a clearinghouse or insurance payer.

Clearinghouse

The benefits of using a clearinghouse are:

  • Check or “scrub” claims for errors before submitting to insurance payer.
  • Can send one batch of claims to several insurance payers.
  • Central location for checking claim status with insurance payer.
  • Allows correction and resubmittal of individual claims when an error is found.

Some practice management software providers also provide clearinghouse services so the claims are sent directly to the clearinghouse.

Otherwise you create an electronic claim file from the practice management software. Print to a file instead of paper. This file is then uploaded to the clearinghouse.

Each clearinghouse will give instructions on how to create and upload claim files but in general if you can print a paper claim, you can create an electronic claim.

If you submit directly to insurance payers without a clearinghouse, the concept would be the same. Claims would just be transmitted (or uploaded) to each individual payer instead of the clearinghouse which can be very time consuming if you have a lot of claims and payers.

Claims Ready for Transmission to Clearinghouse

Uploaded Claim at Clearinghouse

Claim Attachments

The best way to handle claim attachments is through the clearinghouse. Most have the capability to attach electronic documents to a claim but will require setting this for the specific insurance payer(s) before trying to send an attachment.

Many billing specialists resort to paper claims when having to attach information or documentation to a claim. However submitting claim attachments electronically can be done easily and will speed up claim processing and payment.

Claim Must Clear Multiple Hurdles

The lifecycle of an electronic claim involves clearing several hurdles before it can be processed and paid:

  • Checked or “scrubbed” by practice management software prior to transmission.
  • Checked for errors when transmitted or uploaded to the clearinghouse.
  • Insurance payer performs check prior to acceptance for processing from the clearinghouse.
  • Even when accepted for processing or Adjudication by the insurance payer, the claim may still be adjusted or denied due to coding issues.

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