How Claims Are Reviewed Before Submission

Why claims are reviewed before they are submitted

A pre-submission claim review is the set of checks applied after a claim is built and before it is sent to the clearinghouse. The goal is simple: send a claim the payer can process the first time, with codes the documentation supports and the patient's coverage verified.

This article explains what the review checks, which parts follow fixed rules, and which parts need a person who knows the specialty. If you are new to the claim cycle, start with our medical billing process guide.

The checks in a pre-submission review

Coverage and eligibility

Review starts with coverage. Batch checks before the visit day flag inactive coverage, plan changes and high deductibles, and staff confirm details the electronic response leaves unclear. See eligibility verification for the checks that matter most.

Coding support

Codes are compared with the visit documentation. Reviewers confirm that the note supports the level and procedures billed, that diagnosis codes support medical necessity, and that payer-specific bundling rules are respected. Suggestions from any coding tool are reviewed by a coder before use; the clinician's documentation remains the basis for the code.

Edits, modifiers and authorizations

Claims are checked against code-pair edits, modifier rules and the practice's own submission history. Required authorizations are matched to the service and date span. Our guide on how to reduce claim denials covers what happens when one of these checks is missed.

What review cannot do

• It cannot fix wrong demographics, inactive payer enrollment or an incorrect NPI on file.
• It cannot add work that was not documented; documentation drives coding.
• It cannot keep up by itself when payer policies and contract terms change during the year.
• The practice remains responsible for claims submitted under its NPI, whatever tools were used.

How Fastora handles claim review

Every claim passes the edits above, and exceptions go to a reviewer who works in the practice's specialty. Denial patterns feed back into the review rules, so the same error is less likely to repeat. This work sits inside our claims management service and medical coding service.

Frequently asked questions