Choose a clearinghouse

A clearinghouse translates, validates, routes, and returns your claims and remittances. Choosing well matters most for multi-entity groups and for anyone who wants programmatic access to their own claim data.

​

Prerequisites

• Your actual payer mix, listed
• Your claim formats, 837P, 837I, 837D
• Your entity count now and in three years

Consider asking your EHR. Many EHRs embed a clearinghouse and make switching difficult or impossible. It is far easier to choose an EHR that permits your clearinghouse than to change clearinghouses later, which means remapping every payer, re-enrolling EDI and ERA across your whole payer list, and running parallel for a period.

​

The evaluation criteria

​

What matters most for MSO-PC groups

Two criteria carry more weight for MSO-PC groups than for a single practice, and both are worth pressure-testing before you sign. A real API, not a portal with an API attached. If you want automated eligibility at scheduling, per-entity denial analytics across ten PCs, or an AR waterfall built from 835 data, you need a vendor that exposes eligibility (270/271), claims (837P, 837I, 837D), claim status (276/277), 277CA acknowledgments, and 835 retrieval over a modern API. Read the developer docs, not the sales page. Newer API-first vendors such as Stedi sit at one end of this spectrum; legacy clearinghouses with bolt-on APIs sit at the other. Multi-entity configuration and pricing you can compare. A group running one PC per state needs per-entity submitter configuration without a separate contract per entity, and pricing you can model across all of them. Published, metered per-transaction pricing is comparable across vendors; quote-based pricing across four vendors and eleven entities is not a comparison — it is a negotiation. Enrollment treated as a product. Payer enrollment for ERA and EFT is what silently costs new groups months. Evaluate any vendor on how they handle it, not on claim price alone.

​

Honest caveats

• If nobody on your team writes code and your EHR ships with a working embedded clearinghouse, the integrated option may cost less in total effort even if it is the weaker product.
• Newer entrants have shorter track records and smaller installed bases than Optum, Availity, or Waystar. If your requirement is “the clearinghouse my legacy on-premise PM system already has a certified interface to,” that points elsewhere.
• Verify payer coverage for your own mix against each candidate’s published network before committing, rather than trusting any vendor’s headline count.

The full four-way comparison of Optum (Change Healthcare), Availity, Waystar, and Stedi, including the 2024 Change Healthcare outage, is in The clearinghouses, compared.

​

Steps

​

Concentration risk

The 2024 Change Healthcare outage stopped claim submission and remittance for a large share of US practices for weeks. Whatever you choose:

• Hold cash reserves sized to survive several weeks with no collections. This is the only mitigation that works regardless of cause.
• Know your fallback, which payers accept direct portal submission, and whether a secondary clearinghouse could be stood up.
• Keep your data portable, so you can move.

See What is a clearinghouse?.

​

Verify it worked

• EHR compatibility confirmed in writing
• Your top 20 payers verified by name against the payer list
• Enrollment support process and turnaround understood
• All required claim formats supported
• Multi-entity submitter configuration tested
• SOC 2 reviewed
• Total cost modeled across your entity count
• Fallback plan documented