Clearinghouse
A clearinghouse is an intermediary that receives claims from providers, scrubs them against payer edits, and routes them electronically to the right payers — returning rejections and remittances.
Updated
A clearinghouse sits between a provider’s billing system and the payers. It accepts submitted claims, checks them against format and payer-specific edits, translates them into each payer’s required electronic format, and forwards them — then routes the payers’ rejections and remittances back to the provider.
It is a category of system, not a specific product: named clearinghouse products are examples of the concept, never the concept itself. HIPAA defines the category functionally rather than commercially — a health care clearinghouse is an entity that “processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction”, or does that translation in reverse — and the definition expressly includes billing services, repricing companies and value-added networks and switches.
In practice
A clearinghouse catches many format and data errors before a claim reaches the payer, so a claim rejected at the clearinghouse can be fixed and resubmitted without ever counting as a payer denial. That front-line scrubbing is part of what lifts the clean-claim rate.
Commonly confused with
- Payer: The payer adjudicates and pays the claim; the clearinghouse scrubs and routes it on the way there and back.
- Practice management system: The practice management system creates the claim; the clearinghouse transmits it to the payer.