A clean claim is cheaper than a worked denial every single time. The point of medical claim submission services is not to catch errors after a payer finds them. It is to stop the claim leaving with the error on it, and to get it out fast enough that the filing clock is never the thing you are fighting.
What gets checked before a claim leaves
Charges are entered from your documentation, then every claim runs through payer-specific edits, the current NCCI procedure-to-procedure pairs and MUE unit limits, and the local coverage determination for the payer in question. Demographics, subscriber ID, referring NPI, taxonomy and place of service are validated against what the payer expects, because those fields produce the boring, avoidable CO-16 rejections. Diagnosis pointers are checked so a 99214 is not linked to a screening code the payer will not pay a problem visit against. Modifier 25 on an E/M billed with a same-day procedure is checked for a separate note element, and modifier 59 pairs are checked against the NCCI table before they leave, because a CO-97 or CO-4 that comes back in three weeks costs more than thirty seconds now.
Rejections versus denials
A clearinghouse rejection never reached the payer, so it is not a denial and it does not need an appeal. It needs correcting and resending, quickly, before the filing window closes. Medicare allows 12 months from the date of service; many commercial plans allow 90 or 180 days, and a claim that bounces twice at the clearinghouse can quietly eat a third of that. A payer front-end rejection with remark MA130 is the same thing under a different name: unprocessable, no appeal rights, fix and resubmit. Rejections are worked the day they land rather than batched, which is what keeps them from ageing into CO-29 timely-filing write-offs.
You keep your own system
Claims go out of your practice management system through your clearinghouse, not ours. There is no migration, no data export and no period where you cannot see your own claims. You keep the audit trail, the 999 and 277CA acknowledgment reports and the submission log, and you can pull any of them without asking us for it. If you ever move vendors, nothing has to be rebuilt.
How claim submission runs day to day
Encounters close in your EHR, and the charges for them are entered from the note, the superbill or whatever charge capture your providers already use. Each batch is scrubbed, released as 837P claims through your clearinghouse, and the acknowledgment reports are read the following morning rather than left in the clearinghouse inbox. Anything the clearinghouse or the payer front end rejected is corrected and resent that day. Paper CMS-1500 claims for the payers that still require them are printed, mailed and logged on the same schedule as the electronic batch. Once the primary pays, the secondary goes out with the primary's adjudication attached. By the end of each week you have a submission log showing what went out, what was accepted, what was rejected and what was done about each rejection.
What you provide and what comes back
To start, we need access to your practice management system and clearinghouse, your current fee schedule, your payer list with the identifiers each one uses and a way to reach the person who can answer a documentation question. In return you get a daily submission log, a rejection log that records the reason and the fix for every rejected claim and a weekly report from your named account manager. Claim submission does not sit on its own. What eligibility verification catches before the visit determines how many claims are clean, and medical coding decides what is on the claim in the first place. Where a rejection traces back to either step, the finding goes back to that step, with the claim.
How to tell whether your current vendor scrubs properly
Ask for last month's clearinghouse rejection report and the date each rejection was resolved. A vendor that scrubs properly can produce both without effort, and the gap between rejection and resubmission will be measured in days rather than weeks. Ask whether payer-specific edits are configured for your top payers or whether the scrubber runs only the generic edits the clearinghouse ships with. Ask how often claims are batched, because once-a-week batching quietly adds a week to every payment. Ask how many CO-29 write-offs were taken last quarter, since each one is a claim that existed and was never sent in time. Finally, ask to see the submission log in your own system. If claims are submitted from a system you cannot log into, you do not own your audit trail, and moving vendors later becomes much harder than it needs to be.
What Is Included
- Payer-specific edits, NCCI pairs and LCD checks before release
- Electronic 837P claims, paper CMS-1500 where required
- Clearinghouse rejections corrected and resent the same day
- Secondary claims filed as soon as the primary posts
- Daily submission log inside your own system
| Medicare filing deadline | One calendar year from the date of serviceSource: CMS, Medicare claim submission period |
|---|---|
| Coding edits applied | NCCI procedure-to-procedure pairs and medically unlikely edits, updated quarterlySource: CMS, National Correct Coding Initiative |
| Unprocessable claim remark | MA130 means the claim is unprocessable and carries no appeal rights; it must be corrected and resubmittedSource: X12, Remittance Advice Remark Codes |
Claim Submission & Scrubbing: Common Questions
Inside one business day of receiving your documentation, and same day for practices that get charges to us before mid-afternoon. The clock starts when the note is signed, so late charting is the one delay we cannot remove for you.
No. We work inside the system you already use. If you are unhappy with your system that is a separate conversation, and not one you need to have to start.
It is corrected and resubmitted the same day rather than queued. A rejection never reached the payer, so the filing clock is still running and speed matters more than for a denial.
Yes. Some payers, some workers compensation carriers and some secondary claims still require a paper CMS-1500, and those get printed, mailed and tracked the same way electronic claims do.
Once the primary remittance is posted, the secondary claim goes out with the primary payer's adjudication attached, electronically where the payer accepts it and on paper where it does not. Secondary balances are tracked on the same log as primaries so they do not fall between the cracks.
It starts with the free A/R review, then a parallel run of two to four weeks in which we submit alongside your current process and compare results before you switch anything over. Nothing is switched until you have seen the two side by side.