Achieve a Clean Claim Submission Process in 5 Easy Steps

April 19th, 2022 /
Shani Yellin
/ 5 Min Read

While medical providers are in business to take care of people, getting paid for offering those services is also important. The claim submission process in medical billing is a major part of that. A good claim submission process means faster turnover rates in accounts receivable and better cash flow and revenue management. Take a closer look at the claim submission process.

An Overview of the Claim Submission Process in Medical Billing 

Medical Billing

Submitting a medical claim is the process that involves a healthcare provider submitting a bill to a patient’s insurance provider for payment. The claim offers unique medical codes, or CPT (Current Procedural Terminology) codes, that reflect the services rendered during the patient’s visit. When a provider submits a clean claim or an error-free claim, the claim moves through accounts receivable quickly and payments occur quicker. 

What is Included in a Medical Claim? 

A general medical claim contains all the information a payer needs to know in order to reimburse a care provider for the covered services. The three most important aspects of any medical claim include: 

  • Basic patient information, including full name, birthday, and address 
  • The provider’s NPI (National Provider Identifier) 
  • CPT codes that reflect the provided services 

The claim also contains information about provider charges and other pertinent information. Lastly, the claim detail section offers information regarding secondary diagnoses and National Drug Codes (NDCs). 

What Happens After a Claim Submission? 

Today, most claims are submitted electronically. However, in rare circumstances, claims are submitted in paper form too. Once the claim is submitted, it goes through an adjudication process in which the payer determines whether the claim is accepted, rejected, or denied. 

Claim Submission process

Accepted claims are paid to the provider, even though reimbursement is not always 100 percent of what the provider charges. Rejected claims—usually due to some type of error—are returned to the provider for correction with no payment. 

Denied claims are also returned to the provider with no payment. Rejected and denied claims are common. For example, Medicare Advantage denies an average of 8 percent of claims, and some payers initially deny up to a third.

Around 18% of claims are denied due to lack of coverage of certain services, but 9% are denied due to lack of prior authorization. 

5 Easy Steps To Achieve Clean Claim Submission Rate 

Unfortunately, claim denials are common, and 65 percent of them are never reworked. Therefore, it is important to submit a clean claim from the beginning. Filing a clean claim is critical for quick accounts receivable turnover rates.

Claim Submission Process
Click to view image

Here are five easy steps to achieve a clean claim submission rate. 

1. Ensure patient information is correct 

Patient information errors are a frustratingly simple reason for a medical claim to be denied. You can avoid these errors by keeping patient information up to date within the electronic health record (EHR) and revisiting this information every time a patient visits. 

2. Follow a stringent prior authorization process 

Checking with a payer to ensure certain treatments are covered can be a time-consuming but necessary process. Before a patient is scheduled for a visit, be sure to obtain prior authorization. It is recommended to obtain prior authorizations at least five days before the day the service is performed. This lowers the likelihood of claims denials substantially. 

3. Follow the latest medical coding guidelines 

latest medical coding guidelines

Medical coding guidelines are ever-changing. Even if you have office staff that handles medical billing, it can be difficult for them to stay on top of the current changes. For this reason, it is more logical to outsource your medical claims billing. Medical claims billing services dedicate the whole of their time to specifically medical billing. Therefore, they remain updated on all new information regarding changes to codes and how they should be assigned. 

4. Make sure the right modifiers are used 

Different payers have different guidelines regarding which modifiers can be used. Therefore, before the claim is submitted, it is important to understand which modifiers should be used with different payers. Otherwise, the systems the payer uses may not recognize the modifiers eventually leading to denied claims. 

5. Perform quality checks prior to claims submissions 

Quality checks are an important final step before claims submission. During the check, several things should be reassessed, such as patient demographics, medical codes and modifiers used, and other pertinent details. Some medical claims billing software uses what is referred to as a claims scrubber, which “scrubs” each claim in search of errors before submission. 

Key Takeaways to Remember on Medical Billing Claims 

The claim submission process in medical billing can be complex. When handled appropriately, the claim’s processing flow is straightforward and rewarding. Clean claims result in fewer claim denials, which keeps accounts receivable times low. If you are looking for the latest solutions for medical billing or revenue cycle management, reach out to us at PrognoCIS. 

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