The patient is
seen by the provider and a claim that details the visit is created
and uploaded to a batch file that is submitted, either automatically or
manually, to an outside entity called a clearinghouse. Most claims submitted
electronically will go through a clearinghouse because most billing systems
lack the ability to translate every claim to the correct format that each
insurance carrier may need.
So what is a Clearinghouse?
billing, the middleman between the provider and the insurance carrier is called
a clearinghouse. A clearinghouse's role is to:
- Scrub the
for errors and verifying that the claim is compatible with the payer
policies and procedures that protect electronic Protected Health Information
(PHI) from unauthorized access and is responsible for reporting any breach
of data to the affected parties in order to comply with HIPAA
- Provide a service to
both providers and insurance carriers by ensuring faster more
accurate submission of claims, EOB’s and payments. Both will pay the
clearinghouse for the service they provide. Both will be enrolled to send
and receive claims.
claims that go through the clearinghouse will have an electronic date
stamp that shows the date the claim was transmitted and the date the claim
was accepted by the health carrier. This is the assurance that the claim
is on file at the health plan and that it has passed the clearinghouse
Once the claim is
transmitted to the Clearinghouse, the claim will be checked for errors. If
errors are found, the claim will be returned back to the medical biller for
correction and then resubmission.
Some of the edits
that a Clearinghouse could check for are:
ID number is correct.
procedural and diagnosis codes are correct.
procedure being performed fits the diagnosis.
relationship to the subscriber is correct.
patient’s name and date of birth is correct.
COB calculations are correct.
are properly enrolled to submit claims electronically to that carrier.
are submitting to the correct carrier.
carrier accepts electronic secondary claims.
with errors need to be fixed immediately
the claim is not corrected and resubmitted, it will remain in
a holding pattern, unprocessed and aging until some human takes
the time to review it.
health carrier will have no record of these claims because they would have
been returned prior to reaching the health carrier.
an error could be as simple as correcting the spelling on the
patient's name, calling the patient for updated insurance information,
or it could be a claim that cannot be submitted electronically, requiring
billing by paper.
way to fix the error will vary but ALL errors should be fixed daily.
Please be aware
that an error free claim does not guarantee that the claim will be paid nor
does it mean that this same claim will be deemed error free by the health
carrier. Most health carriers will subject a claim to a wide range of
not only submit claims but most have a host of other services such
as eligibility verification, paper claim submission, patient invoicing and