Claim Submission Process In Medical Billing
- Author : Mark Twain
- Date : 30/07/2025
Succesful claim submission isn’t just about send claims to the relevant payers. The process starts the minute a patient schedules a consultation with you. The claim submission process in medical billing might not be as simple as it looks.
Claim submission is that part of the billing process where the medical biller submits the claim to the payer for reimbursements. Though there are a few steps that has to be taken care to prepare the claim for submission, the claim submission part itself needs attention to detail to ensure clean claim submission.
In this blog, we will discuss clean claim rate, the importance of submitting clean claims in healthcare, and some practical tips to enhance your claim submission process. The tips are from a professional medical biller, so make sure you don’t miss them out.
Key Players Involved in The Claim Submission Process
The main characters of the whole claim submission story include a doctor/physician, a payer, and a medical biller. The doctor’s job is to only provide patient care while the payer has to make sure the submitted claim is accurate and legally compliant. A medical biller is the one making things easier for both the doctor and the payer by submitting claims that align with the payer policies and can get maximum reimburements for the doctor.
In some cases, clearing houses are also part of the claim submission. Their job is to make sure the claim has no coding, informative, or compliance issue before it is sent to the payer. Various EHRs come with builtin clearing houses, allowing medical billers to submit claim with higher accuracy.
All You Need For Claim Submission
A medical biller needs some basic information to initiate the claim submission. Here are the basic requisites to start the claim submission process.
- Accurate patient information
- Verified insurance eligibility
- Proper documentation and coding (ICD-10, CPT, HCPCS)
- Encounter notes and provider signatures
Step-by-Step Claim Submission Process
Here is a detailed explaination for the claim submission process. We divided into various steps to make it simple for you to understand.
Charge Entry
Often done by a medical scribe, charge entry is the first step of the claim submission process. It involves the recording of services rendered and charges associated. A medial scribe or transcriptionist will update charts in the EHR to begin the claim submission process.
Medical Coding
Medical coding is the process of translating services into standardized codes. Insurance companies accepts claims in a specific language often known as ICD, CPT, or HCPCS codes. A medical coder translates all the services and procedures into relevant ICD or CPT codes as per the regulations set by the payer.
Claim Creation
Once the coding is done, a medical virtual assistant or a biller starts populating the CMS-1500 or UB-04 form. This is the original file/claim that is to be sent to the payer for reimbursements after it passes through a couple more steps.
Claim Scrubbing
Claim scrubbing is done by the biller in order to check for errors or inconsistencies that may result in a denial or a rejection. Comparing codes with the services provided, double checking the modifiers used, and verifying the patient information for accuracy are some of the tasks done at this step of the claim submission process.
Claim Submission to Clearinghouse
Though this is not very common these days, medical billers previously used to send their claims to a third party company that acted as a clearing house for inaccurate claims. The purpose of the clearing house is similar to that of a claim scrubbing specialist. Nowadays, EHRs have built-in clearing houses for efficiency and compliance.
Forwarding to Insurance Payer
Now the claim is ready for submission. The medical biller or virtual assistant will forward it to the insurance company or the payer as per the guidelines set by the government and the payer. The payer then reviews the claim which is known as claim adjudication process (to be discussed further in this blog). Every payer has their own way of receiving and assessing claims.
Tracking the Claim Status
Now the medical biller or the virtual assistant will actively track claim status through claim tracking tools and portals. Reimbursed claims are instantly updated in the EHR to keep the records straight while the denied or rejected claims are reviewed by the team and the resubmitted with updated information.
Post Claim Submission Processes That You Should Know
Once the claim is submitted to the payer, the adjudication phase begins, where the payer assesses the claim according to a set criteria to check its eligibbilty for reimbursement. Some basic information that every payer assesses in a claim are patient eligbility, active coverage, provider credentials, accuracy of medical codes, and the necessity of medical service provided.
After careful review by the payer, the healthcare provider receives an ERA, also known as Electronic Remttance Advice, as a response to the submitted claim. An ERA contains information about the submitted claim such as total amount billed to the payer, the amount reimbursed by the payer, patient responsibility (copays, deductibles, etc.), and reasons for adjustment or denials if applicable.
Once the claim gets through the adjudication phase, there are three possible outcomes.
- If the claim is approved, payment is sent via EFT (Electronic Funds Transfer) or check.
- The claim is rejected due to issues like incorrect coding, expired coverage, or lack of medical necessity.
- The payer may request documentation such as medical records, notes, or authorizations before making a decision.
Clean Claims - The Key To Getting Maximum Reimbursements
You must be wondering what is a clean claim in healthcare. Clean clain in healthcare is the claim that is reimbursed by the payers in its fullest without any denial. So, its every claim that the biller can get approved by the payer in first attempt. Healthcare providers prefer to have a high clean claim score as it improves the billing cycle, making reimbursements faster and efficient.
A high clean claim rate is very crucial if you want to keep your practice financially stable. You can calculate your practice’s clean claim rate by dividing the number of clean claims to the total number of claim submitted and then multiplying the quotient with 100.
Simple Tips To Improve Your Clean Claim Rate
Double checking your claim before submission is the most common practice used by medical billers to increase the clean claim rate. Advanced practices nowadays are using the latest EHR tools and software to improve the claim submission process, reducing the risk of errors and denials.
Healthcare providers with onsite staff for admin tasks such as billing and claim submission can get benefit by regularly training their employees on the latest billing practices. Besides, most provider achieve high clean claim rate by outsourcing their billing to professional billing companies like Mediclaim Pro Billing.
Outsourcing Your Claim Submissions and Billing To Professional Companies
The outsourcing trend is on the rise and healthcare providers are getting massive benefits by outsourcing their billing and RCM processes to medical billing companies working remotely. This saves the healthcare providers the hassle of hiring onsite staff, providing office space, equipment, benefits, and several other headaches.
Professional billing companies like Mediclaim Pro Billing has experts for each step of the billing cycle, including the claim submission process. These experts are trained on the latest EHR and billing best practices to ensure maximum efficiency. Moreover, legit companies follow HIPAA-compliant processes for secure operations.
With the billing hassle off their shoulders, healthcare providers get to focus on their patients, improving the quality of care. Besides, it ensures a better work-life balance for overworked providers who have to sacrifice their evenings for the boring paper work. Last but not the least, it is a cost-efficient alternative option to hiring onsite staff or managing it by your own.
Frequently Asked Questions
A clean claim is a medical claim that has been accurately completed and submitted without errors, omissions, or red flags. It meets all payer requirements and includes correct patient details, codes, and provider information.
The processing time for a claim varies based on the payer and the claim’s accuracy. On average clean electronic claims are processed within 7–14 business days while paper claim, which are almost extinct now, can take 30 days or longer. Errors or missing documentation can extend the timeline significantly.
A clearinghouse acts as a middleman between the provider and the insurance payer. It checks for errors, scrubs the claim, and forwards it to the appropriate payer.
A payer is the actual insurance company (e.g., Medicare, Aetna, Blue Cross) that reviews and reimburses claims based on the patient’s coverage.
Yes, providers can submit claims directly to some insurance payers using payer-specific portals or software.
The two most commonly used claim forms are CMS-1500 and UB-04 (CMS-1450). CMS-1500 is used for outpatient and professional services while the UB-04 form is used for inpatient and facility-based claims.
Zero denials is the dream of every provider but only a few can achieve it. Following these tips can help you reduce your denials.
- Verify insurance coverage before every visit
- Use accurate and up-to-date coding (ICD-10, CPT, HCPCS)
- Ensure proper documentation of medical necessity
- Submit clean claims through a clearinghouse
- Train staff regularly on billing guidelines
- Follow up on unpaid or denied claims quickly
Working with a professional medical billing company can significantly lower denial rates and improve your practice’s revenue cycle.
