Claim submission workflow basics

A claim begins with a patient encounter and ends when a payment is posted and any balance is resolved. The submission phase covers the middle of that journey: translating a documented service into a clean electronic claim and sending it to the correct payer within the required timeframe. Each hand-off in that process, from documentation to coding to charge entry to submission, is an opportunity for error if there is no clear standard in place.

Charge capture refers to the process of identifying and recording every billable service from a patient encounter. Missed charges, services that were provided but never billed, are a direct form of revenue leakage that cannot be recovered through better follow-up downstream. Charge capture should happen as close to the encounter as possible, and the documentation supporting each charge should be complete before billing proceeds.

• Confirm charges are entered for every encounter before the claim is generated
• Verify that clinical documentation supports the level of service being billed
• Ensure that all services provided during the encounter are captured, not just the primary visit
• Establish a daily charge reconciliation routine to catch missing or incomplete entries
• Flag documentation gaps for provider review before claim submission

Claim scrubbing is the process of reviewing claims for errors and missing information before they are submitted to a payer. This can be done through software edits, manual review, or a combination of both. The goal is to identify and correct problems, incorrect identifiers, missing required fields, non-covered service combinations, while the claim is still in the practice's control, rather than waiting for a payer rejection.

• Run automated claim edits before every submission batch to catch common errors
• Verify that patient insurance information matches what the payer has on file
• Confirm that rendering provider NPI and billing provider information are accurate
• Review place of service codes for accuracy across claim types
• Check for authorization numbers where required before submission

The majority of claims today are submitted electronically, which offers faster processing and more reliable tracking than paper. Electronic submissions go through a clearinghouse that performs additional edit checks before forwarding to the payer. Understanding the clearinghouse rejection reports, and acting on them quickly, is an important part of managing submission workflow. Timely filing limits vary by payer and must be managed carefully to avoid losing appeal rights.

Practices should know the timely filing window for each payer they participate with, and should have a process for tracking claims that have been submitted but not acknowledged. Claims that disappear, neither paid nor denied, require proactive follow-up to confirm they were actually received.

Submission does not mean the work is done. Practices should have a method for tracking the status of submitted claims, confirming that electronic claims have been accepted by the clearinghouse and the payer, and flagging claims that have been in pending status beyond the expected processing window. Without this tracking, claims can be lost or ignored without triggering any follow-up.

• Review clearinghouse reports daily for rejected or pended claims
• Confirm payer acknowledgment for every electronic submission batch
• Flag claims that have not received a response within 30 days for active follow-up
• Maintain a submission log for tracking claim status across payers
• Resubmit rejected claims promptly with corrections to preserve timely filing windows