The claims lifecycle
Our healthcare claims management services cover every step between the visit and the payment. Good medical claims management is less about sending claims quickly and more about sending clean claims the first time, then following each one until it is resolved. Claims management services are one part of our full medical billing services.
Here is how medical claims processing runs at Fastora, inside your existing EHR/PM system:
- Eligibility. Coverage and benefits are confirmed before the visit through insurance eligibility verification, so the claim goes to the right payer.
- Coding. Certified coders assign CPT, ICD-10-CM and HCPCS codes and modifiers, and charge entry is checked against the note.
- Advanced Pre-Submission Claim Review. Each claim is scrubbed against payer and data edits before it leaves the practice.
- Electronic submission. The claim is sent as an 837P transaction through your clearinghouse.
- Claims status follow-up. Acknowledgments are checked, and claims with no response are tracked down.
- Payment posting. Payments and adjustments are recorded through ERA and EOB posting, and any denial is routed for action.
Charge entry and charge capture
Every claim starts as a charge. Charge capture is making sure every billable service from the visit is recorded; charge entry is turning that record into accurate charge lines in the practice management system. Errors here carry through to every later step, so our charge entry services check each encounter before a claim is built.
- Completeness: every visit on the schedule has a charge or a documented reason it does not, such as a no-show or a non-billable visit.
- Correct provider and location: rendering and billing provider, place of service and service facility match the encounter.
- Codes and units: CPT or HCPCS codes, modifiers, units and diagnosis pointers match what the coder assigned.
- Fees: the charge comes from your current fee schedule, not a stale or manually typed amount.
- Authorizations and referrals: numbers attached where the payer required them.
A daily reconciliation of scheduled visits against entered charges is the simplest way to catch missed charges. Charges with open questions go back to the provider or the coding team before submission, not after a denial.
Checking each claim before it goes out
Advanced Pre-Submission Claim Review is Fastora’s name for claim scrubbing. It combines technology-supported edits with a review by our billing staff, so problems are fixed while they are still cheap to fix. As part of our claim scrubbing services, each claim is checked for:
- Patient demographics: name, date of birth and member ID matching the insurance card and payer records.
- Payer ID: the correct electronic payer ID for the plan, not just the insurer’s name.
- NPI and taxonomy: rendering and billing NPIs, and a taxonomy code that matches how the provider is enrolled. A provider who is not yet enrolled with the payer is caught here and routed to credentialing and enrollment instead of being billed and denied.
- Code-to-diagnosis linkage: each procedure line pointing to a diagnosis that supports it.
- Modifiers: present where required and consistent with the documentation.
- Authorization numbers: included when the service required prior authorization.
- Place of service: a code that matches where the service happened, such as office or telehealth.
- Timely filing: the claim is still inside the payer’s filing limit, which varies by payer and contract.
Electronic claim submission and acknowledgments
Professional claims are sent as the HIPAA-standard X12 837P transaction, the electronic version of the CMS-1500 form. Institutional claims, such as many home health and facility claims, use the 837I, the electronic version of the CMS-1450 (UB-04). Our claim submission services use your existing clearinghouse, which checks format and routes each file to the right payer. For a plain-language overview, see what a clearinghouse does.
After electronic claim submission, acknowledgments come back in layers. A 999 confirms the file was readable, and the 277CA claim acknowledgment reports whether each claim was accepted into the payer’s or clearinghouse’s system or rejected, with a status code explaining why. We review both instead of assuming a sent claim is a received claim.
| Response | What it tells you | What we do |
|---|---|---|
| 999 acknowledgment | Whether the batch file passed syntax checks | Fix and resend a rejected file the same day |
| 277CA claim acknowledgment | Whether each claim was accepted or rejected at the front end | Correct the data on rejected claims and resubmit |
| 276/277 claim status | Where an accepted claim stands: in process, pended, paid or denied | Supply missing information or escalate stalled claims |
| 835 remittance | How the payer adjudicated each line | Hand off to payment posting or denial management |
Checking claims status is the next step. We use payer portals and electronic status inquiries to confirm that a claim is in process, pended for information, paid or denied, and we act on whatever comes back.
Medical claim submission on paper is now the exception. Paper claims are slower to process and harder to track, so we use electronic submission wherever the payer accepts it.
Rejections vs denials: what each one needs
The two terms are often mixed up, but they need different handling.
| Aspect | Rejection | Denial |
|---|---|---|
| When it happens | Before the payer processes the claim, at the clearinghouse or payer front-end edits | After the payer processes the claim |
| Typical cause | Invalid member ID, payer ID, NPI or format error | Coverage, authorization, medical necessity, coding or bundling issue |
| Where you see it | Clearinghouse or payer acknowledgment report | Remittance advice with adjustment reason codes |
| What fixes it | Correct the data and resubmit | Correct and resubmit, or appeal, depending on the reason |
Because a rejected claim was never accepted, it does not count as filed with the payer. That is why rejections are worked daily. Denied claims move to our denial management team, which reviews the reason code and decides whether a correction or an appeal is the right path.
Corrected claims
When a claim has already been processed and something on it was wrong, sending it again as a new claim usually triggers a duplicate denial. Corrected claims are sent with a claim frequency code that tells the payer what the new claim is doing.
- Frequency code 7 (replacement): replaces the earlier claim in full. The payer reprocesses it using the new information, so every line must be included, not just the changed one.
- Frequency code 8 (void): cancels the earlier claim, for example when it was billed to the wrong patient or payer.
On the 837P, the frequency code travels with the payer’s original claim number so the payer can match the correction to the claim it replaces. Payer rules differ: many commercial payers accept replacement claims electronically, while Medicare Part B handles many corrections through its reopening process instead. We follow each payer’s method.
Measuring clean claims and first-pass rate
A clean claim is one the payer can process without asking for more information or sending it back for correction. Two measures show how well the process is working:
- Acceptance rate: the share of claims accepted at the front end without any correction or resubmission.
- First-pass rate: the share of claims paid on the first submission, with no rework, correction or appeal.
A first-pass clean claim rate, measured from your own data rather than an industry claim, is the clearest sign that errors are being caught before submission. Measure yours with our clean claim rate calculator.
Definitions vary between billing companies, so it is worth asking how any figure is calculated before comparing it. Our guide to medical billing KPIs explains how these measures fit with days in AR and net collection rate.
What claims management includes
- Claims created and sent from your existing EHR/PM system, with no software to install and no hidden setup fees.
- Daily work on clearinghouse and payer rejections.
- Status follow-up on claims with no payer response.
- Replacement and void claims sent the way each payer requires.
- Transparent dashboards, monthly performance reporting and a monthly review call, plus custom reports on request.
- A dedicated account contact, and 24/7 dedicated client support.
Want to see where your claims stall today? Fastora offers a free claims audit before you commit to anything, and our pricing page explains how claims work is quoted.
Pre-Submission Claim Review (Claim-Scrubbing Services)
Every claim your practice sends out passes through a simple filter at the payer: is it complete, coded correctly, and consistent with the patient’s coverage? When the answer is no, the claim comes back — either as a rejection that never enters adjudication or as a denial that starts a weeks-long appeal. Pre-submission claim review exists to catch those problems before the claim leaves your office.
What does a review actually catch? The most common issues fall into a handful of categories:
- Coding errors. Diagnosis and procedure codes that do not support each other — for example, a CPT code billed with an ICD-10 code that does not establish medical necessity for that service. Transposed digits, outdated codes, and placeholder characters left in place are the quiet versions of the same problem.
- Modifier issues. Missing, incorrect, or misused modifiers — the classic being modifier 59 applied where a more specific X-modifier is required, or bilateral procedures billed without the correct laterality modifier. Modifier errors are among the most frequent reasons for automated payer edits.
- Eligibility mismatches. The member ID, date of birth, or plan on the claim does not match what the payer has on file, or coverage was not active on the date of service. These are entirely preventable when eligibility verification feeds directly into claim preparation.
- Missing authorizations. The service required prior authorization and no authorization number is attached to the claim — or the attached number belongs to a different service, date range, or provider.
- NCCI edit conflicts. Code combinations that violate the National Correct Coding Initiative edits — mutually exclusive procedures billed together, or add-on codes billed without their primary procedure.
Denial management deals with claims a payer has already rejected — recovery work. Pre-submission review is prevention work: the claim is checked against payer rules, coding edits, and coverage data while it is still in your hands, when fixes take minutes instead of weeks. In practice, the industry calls this layer claim scrubbing services — automated and manual review that runs every claim against a rules engine of payer edits, coding logic, and eligibility data before submission.
Clean claims do not start at the payer’s door. They start in your office, before submission, with a review that treats every claim as guilty until proven billable. The payoff is straightforward: fewer rejections to rework, fewer denials to appeal, and a claims pipeline that moves instead of stalls.
EDI Enrollment and Clearinghouse Setup
Electronic claims do not travel directly from your practice to the payer. They move through a chain: your practice management system, a clearinghouse that formats and routes them, and the payer’s EDI gateway. EDI enrollment is the process of registering your practice with each payer — and with the clearinghouse — so that chain recognizes you and accepts your claims.
What does enrollment involve? For each payer you bill electronically, your practice submits an enrollment application that links your tax ID, NPI, and billing address to the payer’s electronic systems. The payer approves the enrollment, assigns electronic submitter identifiers where applicable, and confirms the connection. The same process applies in reverse for ERA (electronic remittance advice) and EFT (electronic funds transfer) enrollment, which route payment explanations and deposits back to you electronically instead of by paper check and mailed remittance.
Clearinghouse selection matters because clearinghouses differ in payer connectivity, edit libraries, and support. A clearinghouse with direct connections to your highest-volume payers reduces the handoffs where claims get lost. The strength of its pre-submission edit library determines how much of your claim scrubbing happens automatically. And the quality of its enrollment support determines how quickly new payers, new providers, and new locations get connected.
Setup affects claim flow in ways that compound over time. Correct enrollment means claims route to the right payer on the first pass instead of bouncing between clearinghouse queues. Active ERA/EFT enrollment means payment posting starts from structured electronic files rather than scanned paper. And keeping enrollments current — updating them when providers join or leave, when tax IDs change, or when new locations open — prevents the sudden claim rejections that appear months after a change nobody connected to billing.
Charge entry services: catching errors before the claim is built. Charge entry is the step where the visit becomes charge lines in the practice management system — and the last cheap place to catch a mistake. Our charge entry services reconcile scheduled visits against entered charges daily, and send open questions back to the provider or coding team before submission. That is the difference from pre-submission review: charge entry checks the charges going in, while pre-submission claim review checks the finished claim going out. Both matter; the first one costs less to fix. Background: charge entry checks before claims.
Claims submission services that keep first-pass rates high
As a claims management company, we own medical claims submission from charge entry to adjudication. Our claims submission services include electronic claims submission services with clean-claim checks, so every claim goes out scrubbed — diagnosis and procedure codes matched, modifiers correct, units and dates consistent. Our claims scrubbing services run this discipline daily, which is what a good claim scrubbing company sells you on paper; we run it daily and measure it with a clean claim rate report. Clean claim submission services are the goal of every scrub routine we run. Behind the submission window sits full claims processing services: our team tracks each claim through the payer, posts every response, and a medical claims processing company mindset means nothing sits in "sent" without a status. Insurance claim billing services are only worth it if the first pass claim rate stays high — rejected claims never had a chance to pay you. See how pre-submission claim review works before submission.
Claim follow-up services and denied claims recovery
Submitted claims do not manage themselves. Our claim follow up services work the payer queue on a schedule: insurance claim follow up at 15, 30 and 45 days, escalation calls for stalled claims, and rejected claim recovery services that pick up claims the clearinghouse bounced before the payer ever saw them. Rejected claims management is separate from denials — rejections are unprocessed claims fixed and resubmitted, while denied claims recovery covers claims the payer processed and refused. Claim rejection management services categorize every bounce, and the common insurance claim rejection reasons (eligibility, missing authorization, wrong NPI, timely filing) get fixed upstream so they stop repeating. When a denial lands, medical claim resubmission is not always the answer — a corrected claim submission is, using the right frequency code. Our corrected claims submission services file frequency code 7 corrected claim transactions — not voids — which is the corrected claim vs void claim distinction that keeps the payer audit trail clean. Our medical claim appeal letter workflow handles the claims that need a real argument, not a resubmit. Read our guide to corrected claims vs appeals.
Do you handle BCBS and UnitedHealthcare claims submission?
Yes. BCBS claims submission follows each state plan's portal and timely filing rules — Blue plans reject more for eligibility than any other reason, so verification runs before submission. UnitedHealthcare claims submission runs through Optum portals with their own authorization and attachment quirks. Payer-specific follow-up matters because each carrier ages claims differently.
Payment posting, ERA/EOB reconciliation and secondary claims
What is payment posting in medical billing? It is the daily reconciliation of every dollar the practice is owed against every dollar that arrived. Cash posting medical billing work matches payments to claim lines, posts contractual adjustments, and flags short pays the same day. Electronic remittance advice posting keeps ERA files flowing straight into the system; paper EOBs get keyed when they still arrive. The ERA vs EOB distinction matters less than the discipline: every remittance, electronic or paper, is reconciled against expected payment. Insurance reimbursement services and reimbursement management services mean the same thing in practice — confirming you were paid what the contract promised, not just what the payer felt like sending. Secondary claims billing closes the loop: once the primary pays, secondary insurance billing services rebill the balance with the primary EOB attached, so patient statements only go out for true patient responsibility. Guides: ERA vs EOB guide and billing secondary insurance.