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Billing and Claims Processing
Billing converts coded encounters into claims, submits them to the correct payer, and resolves the payer response. Success depends on clean claims, correct forms, knowledge of payer types, and disciplined denial follow-up.
Claim Forms and Identifiers
The CMS-1500 bills professional (non-institutional) services; its electronic equivalent is the 837P.
The UB-04 (CMS-1450) bills institutional and facility services; its electronic equivalent is the 837I.
The ten-digit National Provider Identifier identifies billing and rendering providers; missing or invalid NPIs cause rejections.
Diagnosis pointers link each service line to the diagnosis that justifies its medical necessity.
Clean Claims and Submission
A clean claim has complete, accurate data and needs no additional information to be adjudicated.
Scrubbing reviews claims for errors and missing data before submission to raise the clean-claim rate.
Clearinghouses format, edit, and route electronic claims to payers and return rejection reports for quick correction.
Remittance, Denials, and Appeals
A remittance advice (to providers) or explanation of benefits (to patients) shows how each claim line was paid, adjusted, or denied.
A rejection occurs before adjudication and can be corrected and resubmitted; a denial occurs after processing and often requires a formal appeal.
Always review the denial reason and remark codes before acting; an appeal is a formal request to reconsider, supported by documentation.
Payer Types
Medicare Part A covers inpatient hospital and skilled nursing; Part B covers physician and outpatient services; Part C is Medicare Advantage; Part D covers outpatient drugs.
Medicaid is a joint federal-state program for low-income individuals with state-specific rules and is generally the payer of last resort.
Commercial plans, workers' compensation (job-related injuries), and TRICARE (uniformed services members and families) each have distinct filing rules.
Coordination of Benefits and Timely Filing
Coordination of benefits determines which plan pays first when a patient has more than one coverage.
The birthday rule makes primary the plan of the parent whose birthday falls earlier in the calendar year for a dependent child.
Each payer sets a timely filing limit; claims received after the deadline are typically denied and often cannot be billed to the patient.
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Last updated: July 2026