Claims Submission and Clearinghouse Processes
The path a claim travels
A claim moves from the billing system to a clearinghouse, which edits and routes it to the correct payer. Candidates must understand the claim lifecycle: claim scrub, edits (front-end and payer-specific), electronic submission (837), acknowledgment (277CA), and remittance (835). Clearinghouses do not adjudicate; they translate, validate, and transmit.
Concepts to master
- Claim edits: NCCI, medical necessity, data completeness, and payer-specific rules.
- Electronic data interchange (EDI) transaction standards: 837P/I, 270/271, 276/277, 835.
- Timely filing deadlines and proof of timely submission.
- Clean claim definitions and first-pass acceptance rates.
- Rejection versus denial: a rejection never reached the payer's adjudication system.
Traps in questions
A common trap is treating a clearinghouse rejection the same as a payer denial. Rejections must be corrected and resubmitted; denials require appeal or correction. Another trap is assuming a 277CA acknowledgment means the claim was paid; it only confirms receipt. Questions may also test whether a claim can be resubmitted after timely filing has lapsed; usually it cannot without an appeal or exception.
Rule of thumb
Rejections are fixed, denials are appealed. Track first-pass acceptance and front-end rejection rates as leading indicators of billing health.
Worked example
A claim is rejected for a missing NPI. Because it never reached the payer, the timely filing clock has not started in most jurisdictions. Correcting and resubmitting the claim is appropriate, and the original submission date should be documented.