02 — Capability · BC-1840.30
Claim Submission & Remittance
Send each payer a clean, complete claim promptly, follow it to payment and post what each payer paid and adjusted against the account. Applying cash outside patient care is receivables accounting.
- Claims Billing
- Hospital Billing
- Professional Billing
- Third-Party Billing
In scope
- Claim edits, scrubbing and holds
- Claim transmission through a clearinghouse and paper claims
- Claim status follow-up and secondary and tertiary billing
- Electronic remittance and payment posting
Out of scope
- Denials and appeals (see BC-1840.40)
- Receiving and adjudicating claims as a health plan (see BC-1870.40)
- Cash application for non-patient revenue (see BC-250.40)
Realized by · 3
- Epic · Revenue Cyclecore via BC-1840.30.10
- Oracle Health · Patient Accountingcore via BC-1840.30.10
- MEDITECH Expanse · Revenue Cyclecore via BC-1840.30.10
Used in · 2
Build it · 1
Governed by · 1
Decomposes into · 5
- BC-1840.30.10Claim Scrubbing & EditsCheck each claim against payer and coding edits before it leaves, correct what fails, and keep the edit rules current.
- BC-1840.30.20Claim TransmissionSend institutional and professional claims to every payer electronically through a clearinghouse or on paper, and resolve rejections at the front door.
- BC-1840.30.30Claim Status Follow-UpWork unpaid claims by age, payer and value, check status electronically and act before timely filing limits pass.
- BC-1840.30.40Secondary & Tertiary BillingBill each further payer in coordination of benefits order once the earlier payer has paid, with that payer's remittance attached.
- BC-1840.30.50Remittance PostingPost payments, contractual adjustments and denials from electronic and paper remittances to each account, and reconcile deposits to the bank.