Prerequisites
- Payer contract executed, clinician credentialed, effective dates known
- EDI enrollment approved for the payer
- Eligibility verified and the 271 saved
- Authorization obtained and captured in the structured field
- Encounter documented and coded
The clean-claim checklist
Run before submission, ideally as automated scrubber edits rather than human review.Entity and provider data
- Billing provider legal name matches the payer’s records exactly, same as the CP 575 and W-9
- Billing provider NPI is the correct entity’s Type 2 in a multi-PC group
- Tax ID matches the enrollment
- Taxonomy matches what you enrolled and contracted with
- Rendering provider NPI is credentialed and linked to this group’s contract
- Service date is on or after the later of contract effective date and provider effective date
- Referring provider present where the payer requires it
Patient and subscriber data
- Subscriber ID exactly as printed, including any alpha prefix
- Name matches the payer’s record, legal name, not a nickname
- Date of birth matches
- Relationship code correct
- Address current
- Coordination of benefits reflected if there is other coverage
Clinical and coding data
- Diagnosis codes valid and specific to the highest available level
- Procedure codes valid for the date of service
- Modifiers present and appropriate
- Diagnosis pointers link each line to a supporting diagnosis
- Units correct
- Place of service correct, especially telehealth 02 vs 10
- Prior authorization number present where required
- Charges consistent with the fee schedule
Configure the scrubber
Scrubber rejections are free. Payer denials cost 30–60 days. Push everything you can into automated edits.Handle rejections same-day
Two acknowledgments come back, and neither is a denial:
A 277CA rejection is not a denial. Nothing was adjudicated and no determination was made. Correct the data and resubmit as a new claim — do not use a corrected-claim frequency code, because there is no original claim in the payer’s system to correct.
And do not appeal it. There is nothing to appeal.
Work rejections first thing every morning, before anything else. They are the cheapest problems available and they age toward timely filing limits.
The eight causes of most first-claim failures
For a new group or a new payer, in order:- Billing provider NPI not recognized, EDI enrollment incomplete
- Legal name mismatch across the W-9, CP 575, NPPES, and the claim
- Taxonomy mismatch with the enrollment
- Rendering provider not credentialed or not linked to the group contract
- Service date before the provider’s effective date
- Subscriber ID wrong, transposed digits, missing alpha prefix
- Missing authorization number on a service that required one
- Invalid place of service, the telehealth codes especially
Corrected claims
To fix a claim that was adjudicated (denied or paid incorrectly):- Resubmit with the appropriate claim frequency code, 7 for replacement, 8 for void
- Reference the original claim number
- Correct only what needs correcting
Steps
1
Enter charges within one business day of the visit
Days in AR starts at charge entry.
2
Run the scrubber and clear every edit
Every one. An overridden edit is a denial you chose.
3
Submit the batch daily
4
Check 999 and 277CA every morning
5
Work every rejection the same day
6
Run the unbilled encounter report daily and get it to zero
Any completed visit without a charge is revenue that may never exist.
Verify it worked
- Clean claim rate 95%+
- Charges entered within one business day
- Scrubber edits configured, including the auth-required edit
- No edits routinely overridden
- Rejections worked same-day
- Unbilled encounters at zero daily
- Rejection causes tagged and trending down