After a patient receives healthcare services, the provider or practice generates a claim containing details of the services provided. Once the claim is complete, it is submitted for adjudication. If it meets the insurance payer’s requirements, the claim is processed for payment, and the payer closes the claim.
While this sounds straightforward, a clean claim submission in medical billing can be a serious challenge. But why is this so important?
A clean claim submission is one of the most fundamental elements of any revenue cycle. It significantly influences a practice’s financial performance and reflects the efficiency of billing operations. However, most nascent practices overlook claim submission mistakes, which result in frequent denials.
According to Experian’s 2025 statistics, 41% of respondents claim that at least one in ten claims is denied. Each denial results in administrative strain during resubmission processes and financial loss for the practice.
Types of Claim Submission in Medical Billing
Understanding the types of claim submission ensures that billing staff understand the dos and don’ts of the process and avoid critical errors. The following are the types of claim submission in medical billing to remember:
Professional Claim Submission
A professional claim is the one used by individual healthcare professionals to collect reimbursement for the services they rendered to their patients. These professionals may include:
- Therapists
- Independent physicians
- Other licensed healthcare practitioners
This claim form is also known as the CMS-1500 form (previously called the HCFA-1500 form). Typically, a professional claim contains the following details:
- Treatment dates
- Services rendered
- Patient’s diagnosis
Insurance payers process the professional claim and determine payment (per applicable contracts and reimbursement policies).
Important Billing Insight: Please note that 837P is the electronic equivalent of the CMS-1500 form. On the other hand, facilities use the 837I for institutional billing.
Institutional Claim Submission
An institutional claim submission in medical billing is done via a UB-04 or CMS-1450 form. As the name suggests, it is typically used by institutions, such as:
- Hospitals
- Skilled nursing facilities (SNF)
- Other healthcare facilities
This form helps institutions collect reimbursement from insurance payers for services and supplies provided during patient visits. The facility typically files a claim for:
- Medications administered
- Emergency room usage
- Ancillary services
A complete institutional claim also includes:
- Revenue codes
- Procedure codes for the rendered services
- Patient and provider details
- Itemized charges
Dental Claim Submission
Lastly, dental providers use the ADA dental claim form to submit claims for dental procedures and services.
Like professional and institutional claims, dental claims consist of various fields that must be filled accurately to reflect the patient’s dental benefit plan information, missing teeth information, treating dentist’s information, and a record of the services provided.
Claim Submission Process in Medical Billing
Claim submission in medical billing is part of a broader seven-step revenue cycle workflow that begins with patient intake and continues through payment posting.
For accurate claim processing, each stage must be executed correctly. Only then can the claim be paid on the first pass. The following seven steps represent the complete process for claim submission in medical billing:
| Stage | What This Step Involves | |
|---|---|---|
| Step 1 | Registration & Eligibility Verification of the Patient | The front-desk or in-house staff collect accurate patient demographics, subscriber information, and insurance details. Eligibility and benefits should be verified before the day of service and rechecked on the date of service. Lastly, the coverage, deductible status, copay, and prior authorization requirements are verified for the planned procedure. |
| Step 2 | Charge Capture | The billing staff documents services provided during the encounter. They assign or verify applicable CPT, HCPCS, and ICD-10-CM codes, modifiers, and place of service. If a service is not captured here, it will not be billed. |
| Step 3 | Claim Creation | Professional claims are submitted electronically using the 837P transaction or on the CMS-1500 form. Institutional claims are sent via the 837I transaction or UB-04 form. The staff completes all required fields, such as the provider NPI, insurance ID, patient demographics, date of service, and diagnosis-procedure linkage. |
| Step 4 | Claim Scrubbing | The claim is run through a claim scrubber, often provided by the clearinghouse. The clearinghouse identifies coding errors, modifier issues, missing fields, payer-specific edits, and mismatches in diagnosis-procedure. Flagged errors are reviewed and corrected by the billing team before submission. |
| Step 5 | Submission to Payer | The claims are submitted to the payer electronically via a clearinghouse (837P/837I). Where required, the claim is mailed using the CMS-1500 or UB-04. The clearinghouse applies payer-specific routing and additional edits before submission. |
| Step 6 | Payer Adjudication | After claim submission, the payer reviews coverage, calculates the allowed amount, validates codes against contract terms and LCD/NCD requirements, and checks for prior authorization. Moreover, the payer issues an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA/835). |
| Step 7 | Remittance Posting & AR Follow-Up | The ERA payment is posted, and underpayments, denials, or adjustments are also identified. All denied claims enter the denial management workflow. Unpaid claims are monitored through AR follow-up based on the practice’s aging thresholds and payer timelines. |
The Role of Clearinghouses in Claim Submission
Claim submission in medical billing may also involve a clearinghouse, which is an intermediary body that:
- Translates the claim into the correct electronic data interchange (EDI) format
- Applies payer-specific edits
- Transmits the claim to the correct payer
Therefore, the clearinghouse becomes an additional layer of quality control between the payer’s adjudication and the provider’s billing system. With their help, professionals can identify certain claim errors before payer submission, reducing avoidable rejections and denials.
Claim Submission Errors & How to Avoid Them
Errors in submitting claims can delay reimbursement and lead to denials. Fortunately, claim submission in medical billing involves predictable stages where professionals can detect and rectify these errors. The following are the most common ones that practices may encounter:
| Error Type | What Happens | How to Prevent It |
|---|---|---|
| Missing or Expired Prior Authorization | Billing the service without prior authorization. | Validate authorization before the service to match the billed CPT code, and monitor expiration dates. |
| Duplicate Claim | The same claim is submitted multiple times for the same patient, service date, and procedure. | Track submitted claims in the practice management system and review pre-existing claims in advance. |
| Invalid CPT or ICD-10 Code | The procedure or diagnosis code is outdated, invalid, or does not meet the payer’s medical necessity requirements. | Use the latest code sets to confirm that diagnosis and procedure codes align with the payer’s coverage guidelines. |
| Place of Service (POS) Error | The POS code does not correspond to the place of service. | Select the correct POS code based on the actual location of service and review it before submission. |
| Late Claim Submission | The claim is filed after the payer’s deadline. | Submit claims within 48 hours of service. |
| Wrong Claim Form | The service is billed on the wrong claim form. | Use CMS-1500 (837P) for professional claims and UB-04 (837I) for institutional or facility claims. |
| Incorrect Patient Information | Patient name, date of birth, insurance ID, or subscriber details do not match the payer’s records. | Verify patient demographics at every visit and run real-time eligibility checks on the date of service. |
| Missing or Incorrect Modifier | Missing, incorrect, or inappropriate modifier for billed service. | Validate modifiers using claim-scrubbing tools, payer rules, and NCCI edits before claim submission. |
Source: AAPC
Streamline Claim Submission with NeuraBill
Claim submission in medical billing is a part of a multi-step process used to send a completed claim to an insurer for reimbursement. Each step is vital, and errors in the process can lead to payment delays, denials, and the risk of audits.
If your practice faces revenue disruptions due to errors in the claim, consider professional assistance. NeuraBill’s medical billing and coding services provide comprehensive support for clean and compliant claim submissions.
