Creating Electronic Claims
Once all patient, provider, and encounter information has been entered into the practice management software, an electronic claim can be created.
This can be done individually or as a batch of claims. Once created these claims are then transmitted or uploaded to a clearinghouse or insurance payer for processing.
The benefits of using a clearinghouse are:
- Check or “scrub” claims for errors before submitting to insurance payer.
- Can send one batch of claims to several insurance payers.
- Central location for checking claim status with insurance payer.
- Allows correction and re-submittal of individual claims when an error is found.
Some practice management software services also provide clearinghouse services so the claims are sent directly to the clearinghouse from the billing software.
Otherwise an electronic claim file is created from the practice management software and printed to a file instead of paper. This file is then uploaded to the clearinghouse for processing and transmission to each insurance payer.
Each clearinghouse has instructions on how to create and upload claim files. Generally if you can print a paper claim, you can create an electronic claim.
If you submit electronic claims directly to the insurance payer without a clearinghouse, the process is similar. Claims are transmitted (or uploaded) to each individual payer instead of the clearinghouse. This can be very time consuming if you have a lot of claims and payers.
Claims Ready for Submission in Practice Management Software
Below is a screenshot from the practice management software showing a list of claims that have been created and are ready for transmitting.
Screenshot of Claims at Clearinghouse
Below is a screenshot of the clearinghouse service showing a claim that has been uploaded. Notice the format is just like the paper CMS-1500 claim form.
One of the easiest ways to handle claim attachments is through the clearinghouse. Most clearinghouse services have the capability to attach electronic documents to a claim but require setting this up for the specific insurance payer(s) before trying to send an attachment.
Many billing specialists resort to paper claims when having to attach information or documentation to a claim. However submitting claim attachments electronically can be done easily and will speed up claim processing and payment.
Claims Go Throuhg Several Checks
The lifecycle of an electronic claim involves clearing several hurdles before it can be processed and paid:
- Checked or “scrubbed” by practice management software prior to transmission.
- Checked for errors when transmitted or uploaded to the clearinghouse.
- When received by the insurance payer claims are checked prior to acceptance for processing from the clearinghouse.
- Even when claims are accepted for processing by the insurance payer, the claim may still be adjusted or denied due to coding issues.
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This topic covered in more detail in Online Fundamentals of Medical Billing Course