What Meridian did
Mrs. Chen, 54, booked a full-body skin exam. The front desk verified eligibility two days before the visit and again at check-in. Dr. Shah saw her, documented the exam, and a suspicious lesion was biopsied. The biller entered charges the same afternoon, the scrubber flagged a missing modifier, the biller fixed it, and the claim went out that evening. A 999 came back in minutes and a 277CA the next morning, both clean.The seven stages of one claim
1
Verify eligibility (270/271)
Before the visit, your system sends a 270 eligibility inquiry and the payer returns a 271 response: is coverage active on the date of service, what plan, what deductible remains, what copay, is prior authorization required.Do this twice, at scheduling and at check-in. Coverage lapses between the two more often than you’d expect, and eligibility failures are the single largest denial category in most practices. Save the 271 response. It is your evidence in an appeal. See Verify eligibility and benefits.
2
Collect at the point of care
Copay, and any known deductible or coinsurance. Money collected before the patient leaves is money you don’t chase for 90 days. See Deductibles, copays, coinsurance, and patient balances.
3
Document the visit
The clinician documents in the EHR. This is clinical work and it belongs entirely to the PC — the MSO provides the system, not the content.Documentation is also the substrate for everything downstream: the code must be supported by the note, and in an audit the note is the only thing that matters. See Billing compliance: the lines you never cross.
4
Code the encounter
Two code sets, doing two different jobs:
- CPT (or CDT in dentistry, plus HCPCS Level II for supplies and drugs), what you did
- ICD-10-CM, why you did it
5
Enter charges and scrub
The biller enters the charges. The scrubber, in the EHR, the clearinghouse, or both, checks the claim against payer-specific edits before it goes out: valid code combinations, required modifiers, NPI and taxonomy alignment, POS validity, authorization number present where required.Scrubber rejections are free. Payer denials cost you 30 to 60 days. Fix everything the scrubber flags. See Submit clean claims.
6
Submit the 837
Your system generates the 837P (professional) transaction and sends it to your clearinghouse, which validates, translates as needed, and routes it to the payer.What’s inside, in brief: the billing provider (your PC, Type 2 NPI, EIN, address), the rendering provider (Dr. Shah, Type 1 NPI), the subscriber and patient, the claim (total charge, place of service, diagnosis codes), and service lines (one per procedure, each with its own CPT, modifiers, charge, units, and pointers to the diagnoses that justify it).See The 837: how claims are told to payers and 837 file anatomy.
7
Read the acknowledgments
Two come back, and they are not the same thing.
A 277CA rejection is not a denial. The claim never entered adjudication, no determination was made, and, critically, it usually does not stop the timely filing clock. Fix and resubmit the same day. See X12 transaction sets.
Rejection vs denial, learn this now
This distinction confuses new billers for months, and getting it wrong wastes appeals on claims that were never adjudicated.
See Claim denials, explained.
The eight things that reject first claims
New groups reject on the same short list, and almost all of it is enrollment data rather than clinical content:- Billing provider NPI not recognized, EDI enrollment isn’t complete for that payer
- Legal name mismatch between the W-9, the EIN letter, NPPES, and the claim
- Taxonomy mismatch between what’s on the claim and what you enrolled with
- Rendering provider not credentialed or not linked to the group contract
- Service date before the provider’s effective date
- Subscriber ID wrong, transposed digits, or the member ID without the alpha prefix
- Missing prior authorization number on a service that required one
- Invalid place of service, especially the telehealth codes 02 and 10, which mean different things
🦷 Dental, you’ll be sending 837D with CDT codes, and dental payers have their own quirks: annual maximums, missing-tooth clauses, and frequency limitations that read like denials but are benefit design.
Test before you go live
Ask your clearinghouse whether the payer supports a test submission, and send one claim before you send a hundred. A single test claim that comes back accepted validates your entire enrollment chain — EDI, NPI, taxonomy, name, and effective date — for the cost of one visit.Your artifact from this step
- One claim accepted at 277CA
- A documented rejection-resolution loop your biller can repeat
- Confirmed EDI connectivity to payer #1
- A saved 271 eligibility response attached to the encounter
Checklist
- Eligibility verified and the 271 response saved
- Copay collected at the point of care
- Encounter documented before charges entered
- Codes assigned by the clinician or a certified coder
- Scrubber run and all edits cleared
- 837 submitted
- 999 received and clean
- 277CA received and shows accepted
- Any rejection corrected and resubmitted the same day
Next
Step 11: Read your first 835 and get paid
The remittance arrives and the money lands.