The Claim Submission Process
How a completed encounter becomes an accepted claim — charge capture, coding, scrubbing, submission, and the acknowledgments that confirm the payer actually has it.
Updated
The claim submission process is the operational workflow that turns a completed encounter into a claim a payer has accepted for processing. It begins when care has been delivered and documented, and it ends the moment the payer acknowledges the claim as received — not when it is paid, and not when it is sent.
That endpoint is the point of the process. Sending a claim is not the same as a payer having it: a claim passes several gates on the way, each of which can return it, and each of which reports separately. A submission process that ends at “sent” is a process with no idea whether it worked.
The process
Confirm the encounter is documented
Coding cannot begin until the clinical documentation is complete, because the record is what the codes have to be supported by. A claim built on a note that is still open is a claim that will need reworking, and every day the note stays open is a day of charge lag the practice spends out of its own filing window.
Performed by: Provider, clinical documentation
Capture the charges
Every billable service from the encounter is recorded. Charge capture is where revenue is most quietly lost: a service that is never captured is never billed, and unlike a denial it produces no artifact to investigate — there is nothing in any queue to notice.
Performed by: Charge entry, provider
Code the encounter
The documented care is translated into the procedure and diagnosis codes that report what was done and why, with modifiers where a service needs qualifying. This step decides what the claim asserts, and every assertion has to be supported by the record rather than by the situation.
Performed by: Coding
Build and scrub the claim
The claim is assembled and run through edits before it goes anywhere — format edits, code edits, and the payer-specific edits that decide whether this payer will accept this claim. Anything that fails is held and corrected here, where a fix costs minutes rather than a round trip.
Performed by: Billing, clearinghouse
Submit the claim
The claim is transmitted as an 837 — through a clearinghouse, which routes and often scrubs it, or direct to the payer. Batch cadence matters here and is easy to overlook: a claim finished on Monday and transmitted on Friday carries four days of lag nobody chose.
Performed by: Billing
Read the acknowledgments
This is the step that is skipped, and it is the one that makes the process a loop rather than a hope. A 999 reports whether the transmission was structurally accepted; a 277CA reports whether the payer accepted the individual claims inside it. Neither arrives with money attached, so nothing forces anyone to look.
A claim rejected here never reached adjudication. It can be corrected and resubmitted as a first submission — but only if somebody read the report. Unread, it ages silently against the filing deadline.
Performed by: Billing
Work the rejections, then confirm acceptance
Rejected claims are corrected and resubmitted; accepted ones are recorded as accepted so the follow-up clock starts from a known date. Only now is the claim genuinely with the payer, and the process hands over to adjudication.
Performed by: Billing
Commonly confused with
- The denial appeal process: This process ends when the payer accepts the claim for processing. The appeal process begins after the payer has adjudicated it and refused. Between them sits adjudication, which is the payer's process, not the practice's.
- Claim follow-up: Follow-up tracks an accepted claim toward payment. This process is only concerned with getting it accepted in the first place — a claim that was never accepted cannot be followed up, because the payer does not have it.
Related Knowledge
- What Is a Medical Claim?
What the claim this process builds actually asserts.
- Submitting Claims
The submission and acknowledgment steps above, explained in depth.
- Charge lag
The metric that measures how long this process takes.
- Claim rejection rate
The metric that measures how often it fails before adjudication.
- The Denial Appeal Process
The process that begins where this one ends.