Accurate claim submission helps avoid denials, guarantees timely payments and maintains steady cash flow for healthcare practices in the USA. This process is very necessary to track the issues related to billing in real-time.
What is Claim Submission in Medical Billing?
The claim submission process in medical billing is the procedure healthcare providers use to send claims to insurance companies for reimbursement. It includes verifying patient details, coding medical procedures, submitting claims electronically or manually & tracking payment status.
Claim submission in medical billing is important because it helps healthcare providers get paid correctly and on time. Many companies offer this service, but MedBrilliance is quickly becoming a trusted choice for perfect and authentic claim submission support.
Types of Claim Submission in Medical Billing
Below is a table summarizing the main types of claim submission used in the USA healthcare system:
Type of Claim Submission
Definition
Electronic Claim Submission (EDI)
Claims are transmitted digitally via Electronic Data Interchange (EDI). It’s the fastest and most efficient method used by most U.S. healthcare providers.
Paper Claim Submission
Claims are manually filled out and mailed to payers using CMS-1500 or UB-04 forms. It’s often used by smaller practices or in cases where electronic submission isn’t supported.
Direct Claim Submission
The provider submits the claim directly to the insurance company without using a third-party clearinghouse. It offers more control but requires technical setup.
Indirect Claim Submission
The claim is sent to a clearinghouse that reviews and forwards it to the payer. This method reduces rejection rates and simplifies compliance.
Batch Claim Submission
Multiple claims are submitted together in a single batch to save time and processing effort, often used for high-volume healthcare facilities.
Step-by-Step Process of Claim Submission
This process involves a series of steps which are necessary to be followed to make sure that claim submission is done smoothly.
1. Collect complete patient information including demographics, insurance details, and contact data to prevent mismatches during claim processing.
2. Confirm coverage, eligibility, and benefits before the patient’s appointment to ensure claims are billed to the correct payer.
3. Convert diagnoses and procedures into CPT, ICD-10, and HCPCS codes with precision to match payer requirements.
4. Record services provided and associated costs accurately in the billing system to generate claim totals.
5. Generate a structured claim file with all necessary codes, patient details, and provider information for submission.
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6. Run automated claim scrubbing tools to detect and correct missing fields, invalid codes, or formatting errors.
7. Send the claim electronically via EDI or through paper mail to the payer, depending on the method accepted.
8. The insurance payer reviews the claim, checks policy compliance, and determines the amount payable to the provider.
9. Record payment details from the payer’s explanation of benefits (EOB) in the billing software.
10. If claims are denied or underpaid, identify the cause, correct the error, and resubmit promptly to recover revenue.
Pro Tips to Optimize Your Claim Submission Process
Here are some pro tips to properly optimize your process of claim submission and avoid the mistakes during the process:
1. Verify Patient Insurance in Real-Time
Always check insurance eligibility before appointments using automated tools. This prevents claim rejections caused by inactive or incorrect policy details.
2. Use Accurate Medical Codes
Ensure all CPT, ICD-10, and HCPCS codes are current and compliant. Incorrect or outdated codes are the top cause of claim denials in the U.S. healthcare system.
3. Implement Automated Claim Scrubbing
Use claim scrubbing software to detect common billing errors before submission. It helps maintain clean claim rates above 95%.
4. Maintain Up-to-Date Payer Rules
Insurance payers frequently update billing rules. Regularly review payer bulletins to ensure your claims align with the latest requirements.
5. Standardize Data Entry Formats
Use uniform formats for addresses, names, and codes. Consistent data entry reduces claim rejections triggered by mismatched fields.
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6. Submit Claims Electronically
Adopt EDI-based submission systems for faster processing. Electronic claims reduce manual errors and shorten reimbursement cycles significantly.
7. Monitor Claim Status Daily
Use billing software dashboards to track pending claims. Early detection of stuck claims helps resolve issues before they delay payments.
8. Handle Denials Promptly
Create a dedicated denial management workflow. Review payer feedback, correct coding or data issues, and resubmit within 48 hours.
9. Train Staff Regularly
Invest in staff training on billing updates, compliance, and payer policies. Skilled billing teams improve first-pass acceptance rates.
10. Audit Claims Periodically
Perform internal audits every quarter. Spot-checking claims ensures compliance and helps uncover recurring documentation errors.
11. Maintain Complete Patient Records
Ensure all documentation supports billed services. Missing physician notes or consent forms can lead to compliance penalties.
12. Use Reliable Billing Software
Choose a billing platform with integrated reporting, real-time claim tracking, and secure data handling to comply with HIPAA standards.
13. Track Key Performance Metrics
Monitor metrics such as First Pass Claim Rate (FPCR), Denial Rate, and Days in Accounts Receivable (A/R) to identify inefficiencies.
14. Communicate with Payers Regularly
Maintain active communication channels with insurance providers. Building relationships helps resolve disputes and understand rule changes.
15. Outsource to a Professional Billing Partner
Partnering with a medical billing service provider in the USA can improve efficiency, accuracy, and profitability. Professional billing teams use advanced tools, follow payer compliance, and focus on reducing claim denials.
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Role of Medical Coding in Claim Submission Process
Medical coding plays a very critical role in the claim submission process and here are a few examples of that:
Coding Component
Used For
Used By
ICD-10-CM Codes
Reporting the patient’s diagnosis
Medical coders, billing specialists
CPT Codes
Describing procedures and services provided
Providers, coders, EHR systems
HCPCS Level II Codes
Billing for non-physician services and supplies
Billing departments, government claims
Modifiers (CPT/HCPCS)
Giving extra info about the procedure codes
Coders, billing teams
Place of Service Codes
Indicating where the service was provided
Billing software, claim forms
NDC Codes (Drugs)
Identifying specific drug products used during treatment
Pharmacy, coders, billers
Revenue Codes
Categorizing hospital or facility charges
Hospital billing departments
Diagnosis Pointers
Linking each service code to a diagnosis
Coders, electronic claim systems
Taxonomy Codes
Specifying the provider’s specialty or field
Billing teams, credentialing systems
Patient Demographics
Including age, sex, insurance ID, and contact information
Front desk, EHR, billing software
Provider Identifiers (NPI)
Identifying the doctor or clinic submitting the claim
Providers, billers, clearinghouses
Payer IDs
Directing claims to the right insurance company
Billing software, clearinghouse platforms
FAQs
1. What is electronic claim submission?
Electronic claim submission means sending medical claims digitally to insurance companies through secure systems, making the process faster and more accurate.
2. What are the two most common claim submission errors?
The two most common errors are incorrect patient or insurance information and wrong coding, both of which can cause claim denials or delays.
3. What is claim submission in medical billing?
Claim submission is the process of sending a healthcare provider’s bill to an insurance company to get paid for the services given to a patient.
Study our latest research articles on Medical Billing Audits. Also check out our latest research article on What is AR Caller in Medical Billing.
We strictly follow all standard medical billing protocols and you can learn more about medical billing services through Wikipedia.
