For many independent practices, medical groups, and even hospital revenue cycle teams, claim submission looks deceptively simple. Services are rendered, a claim is generated, then payment arrives. In reality, the claims submission process is a multi‑step production line. Any defect at one station can ripple downstream into denials, rework, write‑offs, and unpredictable cash flow.
Payer requirements are tightening. Prior authorization rules, medical necessity policies, and editing logic are updated constantly. At the same time, staffing is tight and front‑end turnover is high, which increases the risk that “tribal knowledge” is lost and process variation creeps in.
This article breaks the claims submission process into eight operational steps, explains how each step affects revenue, and outlines the metrics and controls that RCM leaders should put in place. The goal is not just to “get claims out the door” but to design a predictable, measurable path to payment.
1. Front‑End Capture: Registration, Insurance, and Financial Clearance
The first step in the claims submission process is the patient’s entry into your system: scheduling, registration, and verification of coverage. This is where you decide whether a future claim will be clean, delayed, or never billable at all.
Why it matters: Industry studies routinely show that a large portion of preventable denials originate at registration and eligibility. Wrong plan, inactive coverage, missing coordination of benefits, or incorrect subscriber relationships all result in rejections and denials that often require multiple phone calls or appeals to fix. In busy ambulatory settings, these are the errors that quietly drive up days in A/R and staff overtime.
Operational focus areas:
- Standardized intake scripts: Require staff to capture legal name, date of birth, address, insurance ID, group number, and primary/secondary coverage in a consistent order. Even one transposed digit can result in an eligibility failure.
- Real‑time eligibility and benefits: Use automated eligibility tools at scheduling and again at check‑in for high‑risk payers or high‑dollar services. Confirm not only active coverage but also copay, coinsurance, deductible remaining, and benefit limitations.
- Financial clearance rules: For imaging, surgery, infusion, and other costly services, build rules that stop the case if coverage, pre‑cert, or out‑of‑network liability is not confirmed.
Key metrics to monitor:
- Eligibility‑related denials as a percentage of total denials
- Percentage of encounters with eligibility verified before service
- Front‑end collection rate for copays and known patient responsibility
What to do next: Map your current registration workflow step by step. Identify which data elements are mandatory, where they come from (patient vs. portal vs. card scan), and how they are validated. Close gaps with scripting, system edits, and ongoing staff coaching. Small reductions in eligibility errors quickly translate to measurable improvements in first‑pass payment.
2. Clinical Documentation: Building the Financial Record at the Point of Care
Once the patient encounter begins, documentation becomes the foundation of every downstream billing activity. The provider’s note is not just a clinical record. It is also the legal and financial justification for the codes, the billed charges, and ultimately the payer’s allowance.
Why it matters: Incomplete or vague documentation leads to three types of risk. First, under‑documentation that results in downcoding and lost revenue. Second, over‑documentation that does not truly support the level billed, which increases audit exposure. Third, ambiguous documentation that triggers payer requests for additional information, slowing down adjudication.
Operational focus areas:
- Specialty‑specific templates: Use EHR templates that prompt for elements required for common CPT codes in that specialty, such as history, exam, time, and decision‑making details for E/M services, or laterality and approach for surgical procedures.
- Medical necessity clarity: Train providers to connect diagnoses, symptoms, and risk factors directly to the ordered tests or procedures. Many payers are tightening medical necessity criteria and will deny services that appear routine or screening when diagnostic justification is not clear.
- Provider feedback loops: Coding and audit teams should provide periodic, case‑based feedback to providers: missed billable work, insufficient detail, or patterns that could trigger audits.
Key metrics to monitor:
- Documentation‑related denials (including “insufficient documentation” and “records not received”)
- Audit variance between coded level of service and auditor‑validated level
- Time from date of service to completion of signed note
What to do next: Select a high‑volume visit type or procedure and perform a mini documentation audit. Identify what is consistently present, what is missing, and how that aligns with payer policy. Use that analysis to tune templates and create short, specialty‑specific documentation guides for your providers.
3. Charge Capture: Translating Clinical Work Into Billable Services
Charge capture is the bridge between what happened clinically and what is actually billed. It includes both the initial capture of services (superbills, EHR visit coding, procedure logs) and reconciliation against clinical activity to ensure that nothing is missed.
Why it matters: Lost charges are invisible revenue leakage. They do not generate denials, because no claim was ever submitted. In multi‑provider practices and hospitals, even modest leakage on infusions, injections, or procedures can mean hundreds of thousands of dollars annually. On the other side, incorrect or duplicate charges can create compliance exposure and payer recoupments.
Operational focus areas:
- Event‑based charge triggers: Where possible, link charges to documented events in the EHR or ancillary systems, such as imaging performed, injections documented, or procedures completed.
- Daily reconciliation: For high‑dollar or high‑volume departments (imaging, surgery, procedures), reconcile scheduled cases, completed cases, and charges submitted. Any mismatch should be resolved quickly.
- Clear ownership: Define who is responsible for charge entry, who reviews high‑risk charge types, and what SLAs apply to charge lag.
Key metrics to monitor:
- Charge lag: average days from date of service to charge entry
- Missed charge rate: percentage of encounters where a clinical event exists without a corresponding charge
- Charge correction / rebill rate
What to do next: Pick a single high‑revenue service line, such as cardiology procedures or outpatient surgery, and perform a 30‑day reconciliation between schedules, operative reports, and posted charges. Quantify missed or incorrect charges and use the findings to design routine reconciliation reports and accountability.
4. Coding and Edit Compliance: Converting Documentation Into Billable Codes
Once charges are captured, coding translates clinical documentation into ICD‑10‑CM, CPT, and HCPCS codes that payers use to determine coverage and payment. This step is where many organizations attempt to go “faster” and end up trading speed for accuracy and compliance.
Why it matters: Coding errors contribute heavily to denials, underpayments, and audit risk. Incorrect modifiers, missing diagnosis codes that support medical necessity, or inappropriate bundling can all lead to reduced reimbursement or post‑payment recoupments. At scale, even a small error rate in high‑volume codes has a material revenue impact.
Operational focus areas:
- Coder qualifications and specialization: Use certified coders and align them with specialties they understand. For complex specialties like orthopedics, cardiology, or OB/GYN, generalist coders may overlook nuance.
- Code set and policy maintenance: Keep CPT, ICD‑10, and HCPCS libraries current and ensure internal policies are updated for payer‑specific coding rules, such as modifier requirements and bundling edits.
- Pre‑submission coding edits: Implement internal coding edits that catch common issues before a claim enters the general claims scrubber, such as missing laterality, incompatible code combinations, or absent modifiers.
Key metrics to monitor:
- Denials related to coding and bundling, such as “invalid code”, “non‑covered based on diagnosis”, or “inconsistent with modifier”
- Audit error rate by coder or specialty
- Percentage of coder productivity that goes through secondary audit or quality review
What to do next: Conduct a focused coding audit in one specialty that has high denial volume. Identify patterns, such as missing modifiers, underutilized add‑on codes, or payers that apply unique rules. Use those findings to refine internal coding guidelines, update training, and build targeted edits in your practice management system or clearinghouse.
5. Claim Assembly and Validation: Building a Clean, Payer‑Ready Claim
At this stage, all required data elements are consolidated into a claim record: patient details, subscriber information, provider identifiers, diagnosis and procedure codes, service dates, place of service, and charges. The quality of this assembly step determines whether the claim is ready for electronic submission or will be rejected at the first touch.
Why it matters: Many claim rejections occur before a claim ever reaches the payer’s adjudication system. These front‑end rejections waste staff time and slow cash flow. Common drivers include mismatched subscriber information, missing referring provider IDs where required, or invalid place‑of‑service codes for the billed CPT.
Operational focus areas:
- Form configuration accuracy: Ensure CMS‑1500 and UB‑04 (or their electronic equivalents) are mapped correctly in your practice management or hospital billing system. Small configuration errors, such as incorrect rendering vs. billing provider placements or wrong taxonomy, can trigger systemic problems.
- Provider and facility master files: Maintain up‑to‑date NPI, taxonomy, TIN, and location data. Inconsistent master data often surfaces as payer rejections or credentialing‑related denials.
- Basic claim validation rules: Before claims reach a clearinghouse scrubber, your billing system should enforce required fields for each payer and product type.
Key metrics to monitor:
- Rejection rate prior to payer receipt (clearinghouse or gateway rejections)
- Time from charge entry to initial claim creation
- Number of touchpoints required to fix a rejected claim
What to do next: Review a sample of rejected claims over the past 60 days and categorize root causes. Determine how many could have been prevented with better master data, stricter field validation, or improved registration processes. Prioritize systemic fixes over individual staff reminders.
6. Scrubbing and Edits: Using Automation To Raise Your Clean Claims Rate
Claim scrubbers (either embedded in your billing platform or provided through a clearinghouse) apply payer‑specific and industry standard edits before the claim is forwarded to the payer. This is the last major opportunity to detect and correct errors before they become denials.
Why it matters: Organizations with strong scrubbing rules and disciplined follow‑up often achieve first‑pass clean claim rates above 95 percent. Those with weak rules or inconsistent use of scrubber feedback may hover around 80 percent. That 15‑point difference represents a large volume of avoidable rework, delayed cash, and staff frustration.
Operational focus areas:
- Rule design by payer and specialty: Do not rely only on default scrubber rules. Build custom edits for your largest payers and specialties, especially where you see repeated denials (for example, prior authorization flags, NCCI bundling, or frequency limitations).
- Workqueues and ownership: Route scrubber edits into clear workqueues with defined owners and turnaround expectations. If scrubber rejections are “worked when we have time”, they will age and miss timely filing limits.
- Continuous learning from denials: Every recurring denial category should be evaluated for a possible upstream scrubber edit. In other words, bring denial intelligence back into pre‑submission rules.
Key metrics to monitor:
- Overall clean claim rate (first pass)
- Volume and percentage of claims requiring correction after scrubbing
- Average days from scrubber rejection to resubmission
What to do next: Identify the top five denial codes by volume and determine whether a scrubber edit could catch the triggering condition before submission. Start with denials tied to coding, missing information, or invalid combinations. As rules mature, you will see lower denial rates and more predictable cash flow.
7. Electronic Submission and Payer Acknowledgments: Ensuring Timely, Traceable Delivery
Once a claim passes scrubbing, it is transmitted electronically to the payer or to a clearinghouse that routes it onward. This stage might seem mechanical, but there are important controls that protect against “lost” claims and missed timely filing windows.
Why it matters: If claims are sent in large batches only a few times per week, an unnoticed system or connectivity issue can delay entire days of billing. Without monitoring acceptance reports and acknowledgments, teams may not realize claims are stuck until days or weeks later. By then, some claims may already be at risk of missing filing deadlines.
Operational focus areas:
- Daily submission cadence: Aim for daily (or more frequent) transmission of claims to maintain a steady revenue stream and prevent pile‑ups.
- Monitoring 277/999 acknowledgments: Ensure staff monitor electronic reports that confirm claim receipt, acceptance, or rejection. Rejected batches or individual claim errors must be worked quickly.
- Timely filing controls: For payers with short filing windows, automated alerts should highlight encounters approaching the deadline where no accepted claim is on file.
Key metrics to monitor:
- Average days from charge entry to payer acceptance
- Number of claims lost or resubmitted due to transmission errors
- Percentage of write‑offs related to timely filing
What to do next: Review your current submission schedule and acceptance monitoring. Clarify who is responsible for checking acceptance reports, what they do when a file fails, and how quickly they must respond. Formalizing this step significantly reduces “black hole” claims that never arrive at the payer.
8. Adjudication Outcomes, Denials, and Feedback Back Into the Process
The claims submission process does not end when a claim reaches the payer. Adjudication results, payment patterns, and denial reasons contain critical feedback that should shape how you manage every upstream step. Organizations that treat denials purely as back‑end firefighting miss the opportunity to improve the entire submission cycle.
Why it matters: A high clean claim rate is important, but it does not guarantee optimal reimbursement. Payers may underpay without obvious errors on the remittance, or may systematically deny certain services on first submission to see what providers will appeal. Closing the loop from adjudication back to front‑end processes is essential for protecting revenue long term.
Operational focus areas:
- Denial categorization and trending: Classify denials into actionable categories: registration, authorization, coding, medical necessity, non‑covered service, duplicate, timely filing, and payer system issues. Look at both volume and dollar impact.
- Appeal strategies: Develop templates and playbooks for high‑value denial types, such as medical necessity and level of service disputes. Ensure clinical and coding experts are involved where needed.
- Underpayment detection: Use contract management tools or rate tables to compare allowed amounts against contracted fees. Underpayments can be as damaging as overt denials.
Key metrics to monitor:
- Denial rate as a percentage of submitted charges or claims
- Denial recovery rate (dollars recovered / dollars denied)
- Net collection rate and days in A/R by payer and service line
What to do next: Choose one denial category that carries significant financial impact and trace it upstream. For example, if medical necessity denials are high for a specific procedure, review documentation, coding, and pre‑authorization steps for that service. Then implement changes in templates, eligibility prompts, or scrubber rules. This is how adjudication data becomes a continuous improvement engine for your claims submission process.
Connecting the Dots: Designing a Standardized, Measurable Path to Payment
Each step of the claims submission process, from scheduling and documentation to scrubbing and adjudication, is interdependent. A registration error leads to a scrubber rejection. A vague note leads to a coding edit, then a medical necessity denial. A missed authorization leads to a full write‑off. When RCM leaders view these as isolated problems, teams stay trapped in rework. When they view the steps as a single pipeline, it becomes possible to design a standardized and measurable path to payment.
To move in that direction, consider the following framework:
- Define standard workflows: Document the “one best way” to handle registration, documentation closure, charge capture, coding, claim review, and submission for your major service lines. Reduce variation between locations, providers, and staff.
- Assign clear ownership per step: Every step needs a responsible role with defined SLAs. For example, notes signed within 48 hours of service, charges entered within 2 days of signature, scrubber edits resolved within 48 hours.
- Track a compact KPI set: Clean claim rate, denial rate, days in A/R, charge lag, and eligibility error rate, broken down by payer and specialty, will highlight where process improvements deliver the most ROI.
- Invest in training and technology together: Eligibility tools, scrubbers, and contract management are only as effective as the staff who use them. Continuous training in payer rules and internal workflows is essential.
Many organizations find that partnering with experienced billing and RCM specialists helps accelerate these improvements. If your internal team is stretched thin, outside expertise can help redesign workflows, configure scrubbers, and stabilize KPIs faster. One of our trusted partners, Quest National Services medical billing, provides full‑service revenue cycle support for organizations that need deeper operational and payer expertise.
Ultimately, the claims submission process is not just a billing function. It is a core business process that determines how quickly your organization converts clinical effort into cash. By standardizing each step, monitoring the right metrics, and continuously feeding payer feedback back into the front end, you can turn what feels like a chaotic maze into a predictable, high‑yield revenue engine.
If you are evaluating your own claims workflow and want help prioritizing where to start, you can contact us to discuss your current KPIs, payer mix, and operational challenges.
References
Centers for Medicare & Medicaid Services. (n.d.). Medicare fee-for-service 2023 improper payment report. Retrieved from https://www.cms.gov
Change Healthcare. (2020). Revenue cycle denials index. Retrieved from https://www.changehealthcare.com
