Staff Series – R1 M4: Claims & Submission
RCM Foundation Series  ·  Continuity Practice Partners Round 1  ·  Module 4 of 5

Claims & Submission

Round 1 — Module 4  ·  From finished charge to claim in the payer’s hands

Round 1 Progress
1
How It Works
2
Financial Clearance & Check-In
3
Charge Capture & Coding
4
Claims & Submission
5
Payment, Follow-Up & Collections
Overview

The claim has to survive three checkpoints before it reaches the payer

Once a charge is complete and coded, it becomes a claim — a formal request for payment. But a finished charge does not mean a finished claim. Before the payer ever sees it, the claim passes through a scrubbing process, a clearinghouse, and a series of acknowledgment checks. A problem at any point along this path can stop the claim before it is ever paid.

This module walks through what happens to a claim between the moment it leaves the practice and the moment the payer accepts it — and what your role is at each checkpoint.

A claim that disappears somewhere in this process does not come back on its own. If no one is tracking it, the practice may never know it was lost — until the payment never arrives.

The Path of a Claim

Three checkpoints between your office and the payer

1
Scrubbing
Before a claim is released, it passes through scrubbing software that checks for basic errors — missing fields, invalid codes, mismatched modifiers. Claims that fail scrubbing are held, not sent. Someone has to fix the error before the claim can move forward.
2
Clearinghouse
Clean claims are sent electronically to a clearinghouse — a third party that checks the claim again before forwarding it to the correct payer. The clearinghouse confirms the claim format is valid and the payer ID is correct. If something is wrong, the claim is rejected and sent back rather than passed along.
3
Payer acceptance
Once the payer receives the claim, they confirm receipt and accept it into their adjudication system — the process where they decide how much to pay. Only after a claim is accepted does it move toward payment. A claim can be rejected at this stage too, often because the payer cannot identify the patient or the insurance information does not match their records.
Rejection vs. Denial

Two different problems that get confused often

These terms get used interchangeably, but they describe different things that happen at different points — and they are handled differently.

Rejection
A claim that never made it into the payer’s system at all. It was stopped by the clearinghouse or bounced back by the payer before adjudication — usually due to a formatting error, an invalid ID number, or a technical mismatch. A rejected claim has not been reviewed for payment; it simply never arrived correctly. It must be corrected and resubmitted.
Denial
A claim that was received and reviewed by the payer, who then decided not to pay it — or to pay only part of it. Denials happen for reasons like missing authorization, coding errors, or coverage issues. Denials require a different response than rejections: an appeal, a correction, or a write-off, depending on the reason.

If a claim is rejected and the rejection is never worked, the payer has no record of it. They are not ignoring you — the claim genuinely never reached them. This is why claim tracking matters: a missed rejection looks identical to a payment that is simply slow, until weeks have passed and nothing has happened.

Tracking Claims

Why someone has to watch the whole path

At each checkpoint — scrubbing, clearinghouse, and payer — an acknowledgment should confirm that the claim moved successfully to the next step. If a batch of 100 claims is sent and only 92 are acknowledged by the payer, that means 8 claims are sitting somewhere unresolved. Without someone watching for that gap, those 8 claims will simply never get paid — not because the payer denied them, but because they never made it far enough to be reviewed.

This is why claims need to be submitted daily, in batches, with someone responsible for confirming that what went out matches what was received at each stage. A claim that disappears between steps does not generate an error message on its own — it just stops moving.

If a claim has not shown any movement — no acknowledgment, no rejection, no payment — after a week or more, that is a signal to check on it directly rather than assume it is still processing normally.

Your Role in This Stage

What billing staff own in claims and submission

  • Submit claims daily — do not let claims sit and accumulate before sending
  • Review and resolve scrubbing edits before claims are released
  • Check the rejection queue daily and correct rejected claims quickly
  • Confirm that the number of claims sent matches the number acknowledged at each checkpoint
  • Distinguish between a rejection and a denial before deciding how to respond
  • Flag any claim with no movement after a week so it can be investigated
Check Your Understanding
Answer all three questions correctly to unlock Module 5. Select an answer to see immediate feedback.
1. A batch of 50 claims is sent to the clearinghouse, but only 46 are acknowledged as received by the payer. What does this most likely mean?
2. A claim comes back from the clearinghouse because the patient’s insurance ID number does not match the correct format for that payer. Is this a rejection or a denial?
3. Why is scrubbing software used before a claim is released to the clearinghouse?

Module 4 complete — Module 5 is unlocked.

Continue to Module 5: Payment, Follow-Up & Collections →
Continuity Practice Partners  ·  Bend, Oregon
www.continuityrcm.com  ·  info@continuityrcm.com