Perhaps, among their non-clinical duties, the most taxing task for healthcare providers is claim submissions. Why? Because they have to be careful about small billing details, otherwise they face reimbursement denials.
In 2025’s Experian Research, over 40% of providers said that at least 10% of claims are denied. This is a worrisome statistic for medical professionals because denials lead to twice as much work and stress. However, an understanding of the claim-filing process improves revenue cycle management (RCM) in the healthcare industry.
Our goal is to make things easier. We will, therefore, discuss the entire process of claim submission in medical billing. Everything you need to know about medical claims is covered in this guide, including their types and recommended filing steps.
Types of Claim Submission in Medical Billing
Before we dive into the details of claim submission in medical billing, let us explain to you the different types of claims used for medical billing.
A medical claim is a standardized document that medical professionals send to insurance payers for reimbursement of their services. The following are the three main types of claims in billing.
Type 1: Institutional Claim Form
This claim form is also known as the UB-04 or CMS-1450 form. It is called an institutional claim form because it is used by medical institutions, such as hospitals or nursing homes, to collect reimbursement from insurance payers for services rendered during inpatient stays and outpatient visits, such as emergency room usage, ancillary services, and supplies.
This form contains patient details, provider details, procedure codes, revenue codes, and itemized charges.
Type 2: Professional Claim Form
The medical claims used by independent physicians, therapists, and other licensed healthcare practitioners are referred to as professional claim forms (also recognized as CMS-1500 form and the HCFA-1500 form). The details that must be entered in these claims include the patient’s diagnosis, treatment dates, and the services rendered. These details help the insurance payer determine the reimbursement rate for the given services.
Note that the electronic equivalent of CMS-1500 is 837P. Facilities, on the other hand, are required to use 837I for institutional billing.
Type 3: Dental Claim Form
The last type of form that may be used for claim submission in medical billing is an ADA dental claim form used by dentists. These claims are specifically designed to provide details about dental procedures and care to the insurance payer.
Claim Submission Process in Medical Billing
We understand that claim submission in medical billing can be challenging, especially when it is a significant part of the healthcare RCM. However, the task can become easy if you complete the process step-by-step.
The following are the 6 steps of claim submission in medical billing, which will likely simplify things for you.
Step 1: Patient’s Initial Intake
The moment you onboard your patient is when the claim submission process in medical billing actually begins! Patient registration is the initial stage. It includes gathering vital information, medical history, personal data, and the insurance payer’s details. When it comes to medical billing, this information is crucial because missing or inaccurate patient data can lead to claim rejections.
Step 2: Inquiry About Insurance Coverage
This is another crucial step in claim submission in medical billing. You must verify the patient’s insurance coverage and eligibility. This will help you confirm the active policy status, coverage period, service restrictions, and plan benefits. Additionally, some medical procedures require pre-authorization, so you must confirm the payer’s prior authorization rules regarding the service you intend to render.
Step 3: Documentation
Documentation enables the provider to communicate with the payer and explain the details of medical care. Hence, you must keep accurate, up-to-date records and note every service, treatment, and prescription that the patient received. These supporting documents help the payer gauge the medical necessity of the service and decide whether reimbursement should be released or withheld. Contrarily, inadequate documentation results in claim delays or denials.
Step 4: Claim Generation
After thorough documentation, you are ready to generate claims. This step requires all data to be in one place, such as patient information, insurance details, clinical/operative notes, diagnosis and procedure codes, and service charges, which the insurance payer will eventually reimburse.
Step 5: Internal Claim Scrubbing
This is the most crucial step in claim submission, as it will prevent you from submitting erroneous claims. Claim scrubbing tools help professional billers detect incorrect codes, missing modifiers, incomplete patient details, or inadequate documentation before submission. Hence, early error detection can resolve issues that may result in a claim denial.
Step 6: Claim Submission
And now, the final step of claim submission in medical billing is to file the claim. This can be done electronically through clearinghouses or by directly mailing the paper claim to the insurance payer.
Challenges in the Claim Submission Process
Seamless claim submission in medical billing is one of the most challenging tasks. However, the process may become a little less daunting if you are aware of the hurdles in advance. So, let’s discuss some challenges that providers often encounter during claim submission in medical billing.
Incomplete Patient Information
At facilities with high patient volumes, front-desk staff are often working under pressure. This leads to hasty patient verification and missing out on crucial details that are later needed for claim filing. Hence, many billers have to contact the patient again for complete information. And if not done, incomplete or incorrect patient data triggers a denial.
Coding Confusion
Applying inaccurate medical codes is another major reason for claim denials. Medical billing professionals often get confused with the descriptions of CPT, ICD-10, or HCPCS codes, and a lack of understanding of codes results in inaccurate coding.
Delayed Claim Submission
Another mistake that many billers make when submitting medical claims is to miss the filing deadlines set by insurance payers. Claims that are submitted after the deadline are automatically rejected.
Best Practices for Clean Claim Submissions
Now that we have discussed the challenges, what are the best strategies you can implement to file a clean claim? But before that, if you are wondering what exactly a clean claim is, let us clear it up for you. Any medical claim that is free of error, missing information, or any other issue that may lead to a denial is called a clean claim.
So now, let’s find out how you can achieve a clean claim submission in medical billing.
Ensure Accurate Patient Details
As we have already indicated above, it is important to mention accurate and complete patient information for a clean claim submission in medical billing. Healthcare professionals must actively take steps to gather patients’ demographic data and insurance coverage information.
Provide Proper Documents
Ensure that the ICD-10 diagnosis codes and CPT procedure codes applied to the claims accurately reflect the provided services. Furthermore, you must attach operative reports, progress notes, and other records to give evidence for the medical necessity of the services billed.
Comply with Payer Rules
Verify that your claim complies with the insurance payer’s policies because billers might be unaware of the latest revisions in policy manuals and updated federal/state regulations. They may end up filing claims in accordance with the previous rules and laws.
Accelerate Clean Claim Submission with MediBillMD
The financial sustainability of healthcare practices or professionals depends on effective claims submission in medical billing. Not only can rejected claims and late payments affect the practice’s finances, but they can also impact the standard of healthcare services.
Although we have provided all the essential information needed to submit a medical claim, there are still some unavoidable problems that you can run into while submitting a claim.
MediBillMD provides reliable claim submission services to help manage volume, maintain compliance, and ensure timely claim resolution. The good news is that they have a 98% clean claims rate, and 97% of claims are accepted on the first try. If you are considering acquiring medical billing services, then MediBillMD is the right choice for you!
