Before a claim is built, the coded charge is checked against the documentation it came from: CPT/HCPCS and ICD-10 pairing, units, modifiers, and place of service. Anything that doesn't match the note gets routed back before it becomes a claim.
Validated charges are formatted into the correct EDI transaction, an 837P for professional services on the CMS-1500 equivalent, or an 837I for institutional/facility claims on the UB-04 equivalent, with NPI, taxonomy, and authorization numbers attached.
Every claim runs against payer-specific edit logic and NCCI edits before it leaves our system. Mismatched modifiers, invalid code pairs, and missing authorization numbers are caught here, not at the payer.
Claims go out through the clearinghouse in batches, and the 999 and 277CA acknowledgments are checked the same day to confirm the payer actually received and accepted the file, not just that it was sent.
Claims that reject at the payer level are identified through 276/277 status inquiries and ERA 835 remittance review, corrected, and resubmitted within one business day rather than waiting for a manual follow-up call.
Most claims go out within 24 to 48 hours of the charge being validated. Claims that fail the pre-submission scrub are held until the modifier, code pairing, or missing data issue is fixed, so nothing ships knowing it will bounce.
Coding assigns the CPT, HCPCS, and ICD-10 values that describe what happened during the encounter. Claim submission takes those codes and builds them into a complete 837 transaction, correct modifiers, provider identifiers, and payer-specific formatting included, then gets that transaction through the clearinghouse and tracks it until it's acknowledged.
A rejection means the claim never reached adjudication, usually because of a formatting error, an invalid code, or a missing identifier caught at the clearinghouse level. Mentalhealthbilling corrects and resubmits rejected claims within one business day. Denials, which happen after a payer reviews the claim, go through a separate appeals process.
Yes. Medicare's window is 12 months from the date of service. Commercial payers vary, commonly between 90 and 180 days, and some contracts set narrower limits. Each claim is logged against its specific payer's deadline from the date the charge is entered, not a single blanket timeline.
The authorization number is attached to the claim during the transaction build step. If a service was delivered without the required authorization on file, the claim is flagged before submission so it can be corrected or appealed proactively instead of rejecting at the payer.