How Clearinghouses Help in Medical Claims Processing


In the process of medical claims, there are those companies described as intermediaries or middlemen, with the function of forwarding the claims information from the healthcare providers to the insurance payers. Named as the clearinghouse, these companies work by checking the claim for any presence or existence of errors, in the process verifying if the same is in fact compatible with the software used by the payer.

Likewise, it is the clearinghouse’s responsibility to be certain that the procedural and diagnosis codes to be forwarded are valid and that every aspect of the procedure code is indeed compatible with the diagnosis code submitted together with it. The idea behind this scrutiny is to make sure that processing errors, which can be very time consuming are avoided.

Since you’re the healthcare provider planning to hire a medical billing company claims clearinghouse, it is your right to choose one that you think will help you the most. But you do have to remind yourself that most clearinghouse companies will be charging you for each claim successfully submitted plus the additional costs involved in the process, such as sending a paper claim to the payer. There are two ways for claims to be sent; first is when the clearinghouse will submit them to the payers directly, and second is when they’ll send it via another clearinghouse’s site before actually reaching the payer.

 The reason why claims may need to go through other electronic claims clearinghouse  is because your billing software might not be compatible with the processing software of the payer. With the possibility of an incompatible software and the challenges they could pose, it is understandable that majority of clearinghouses will require healthcare providers to submit to an initial enrollment period before sending claims for the very first time. In this period, which usually lasts from three to four weeks, will all be about testing the compatibility of your software to that of the payer.

Nonetheless, you have to look at it as something that benefits you in the long run since its very purpose is to prevent any possible delays in your medical claims in the future. Check out for more details about medical claims.

On the other hand, it is wiser on your part to find another clearinghouse should you find out that the one you are enrolled with always sends the claims to other clearinghouses. There really is no problem is there’s a transition period, but it doesn’t have to be like that forever. Yes, it may be true that hiring a larger company will cost you more, but in the end, it’ll be worth it considering that you’d be expecting to receive payment off those claims on schedule every single time.


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