The full path
Stage by stage
1–3. Before the visit
Scheduling is where revenue integrity starts. Capturing the correct subscriber ID, plan, and demographic data here prevents more denials than any downstream control. Eligibility (270/271). Your system sends a 270 inquiry; the payer returns a 271 with coverage status, plan type, deductible remaining, copay, and coinsurance. Run it at scheduling and again at check-in — coverage lapses between them. Save the 271; it is your evidence in an appeal. Prior authorization (278, or a portal, or a fax). Some services require the payer’s approval before delivery. Missing authorization produces CARC 197, one of the most common and most preventable denials. See Get prior authorizations.4–5. The visit
The patient is seen and the clinician documents. Two things happen here that matter for money:- Point-of-care collection of copay and known patient responsibility. Money collected before the patient leaves is money you don’t chase for ninety days.
- Documentation becomes the substrate for everything downstream. The code must be supported by the note, and in an audit the note is the only evidence that exists.
6–8. Turning care into a claim
Coding. Two code sets doing two jobs: CPT (or CDT in dentistry, plus HCPCS Level II) says what you did; ICD-10-CM says why. Modifiers qualify; place of service codes locate. Coding is an exercise of clinical judgment and, in an MSO-PC structure, it belongs to the PC. The MSO can employ coders and provide the systems; it should not determine what codes are assigned. See What an MSO can and can’t do. Charge entry puts the coded encounter into the billing system. Scrubbing validates against payer-specific edits before submission. Scrubber rejections are free; payer denials cost 30–60 days.9–10. Submission and acknowledgment
The 837 transaction carries the claim to the payer through a clearinghouse. Three acknowledgments can come back:
A 277CA rejection is not a denial — nothing was adjudicated. Fix and resubmit same-day.
11. Adjudication
The payer applies member eligibility, benefit design, the contracted fee schedule, medical necessity policy, coding edits, and coordination of benefits, then determines: allowed amount, payer liability, patient liability, and any denial. This is a black box from outside, which is why the 835’s explanation matters so much.12–13. Remittance and payment
The 835 explains the determination line by line. The payment arrives separately, by EFT, paper check, or virtual credit card. The 835 and the payment are different objects and they do not map one-to-one. One deposit can cover several remittances. Reassociate them using the TRN trace number, not by matching dollar amounts. See The 835.14. Posting
Payments, contractual adjustments, and patient responsibility are recorded against the claim. Auto-posting handles the clean lines; an exception queue catches unmatched claims, takebacks, interest, and secondary transfers. Every dollar of difference between billed and paid is explained by a group code + CARC (+ RARC) triple:15. Denials
Lines paid at $0 with a denial reason go to the denial queue, not to a write-off. The decision is correct and resubmit (the claim had bad data) versus appeal (the claim was right and the payer was wrong). See Claim denials, explained.16–17. The patient balance
PR amounts move to the patient ledger and into the statement cycle. If the patient overpaid, a very common outcome when point-of-care estimates exceed actual responsibility, you owe a refund, sometimes on a statutory deadline. See Patient refunds and credit balances.How long it takes
Total for a clean claim: roughly 20–40 days. For a denied claim that must be appealed: 90–180 days, at meaningfully higher cost.
Where money leaks
Ranked by how much revenue they typically cost:- Eligibility failures, no check, or checked too early
- Authorization failures, not obtained, mismatched, or obtained but not captured on the claim
- Coding and documentation gaps, the note doesn’t support the code
- Credentialing gaps, services billed before the provider’s effective date
- Timely filing, charge entry lag, or a claim lost in a rejection loop
- Unworked denials, a large share of denied claims are simply never reworked
- Unbilled encounters, visits that never became claims
- Underpayments, the payer paid less than the contract requires and nobody checked
- Patient balances written off, instead of collected