Claims Submission & Clearinghouse Management

Claims submission is where coded charges become a request for payment. A claim is checked for errors, sent to a clearinghouse, and passed on to the payer. Mistakes here cause rejections, delays, and rework.

Claims submission services cover the full trip. That includes claim scrubbing, payer-specific formatting, daily submission, and follow-up on every rejection. Clearinghouse management means keeping the connection to payers working, setting up payer enrollments for electronic transactions, and watching reports.

Westmont Revenue Partners connects practices and facilities with vetted medical billing experts who provide outsourced claims submission. We match you with a team that knows your specialty, your payers, and your software.

Who this is for

• Practices with frequent claim rejections or a growing backlog of unsent claims
• Groups that lost a biller and need coverage fast
• Practices that switched software or clearinghouses and are seeing new errors
• Facilities that bill both professional and institutional claims
• Specialties with payer-specific rules, such as behavioral health, therapy, and DME
• Owners who want a daily view of what was sent and what came back

What's included

• Claim scrubbing for missing or mismatched data before submission
• Daily claim batching and electronic submission
• Payer-specific formatting for professional and institutional claims
• Clearinghouse setup and configuration, including payer lists
• Support for electronic enrollment with payers, such as remittance and claim transactions
• Review of acknowledgment and rejection reports
• Correction and resubmission of rejected claims
• Paper claim submission where a payer requires it
• Secondary and crossover claim handling
• Tracking of claims against payer filing limits
• Reporting on submitted, accepted, and rejected claims

How it works

1. The team confirms your clearinghouse setup, payer list, and claim forms.
2. Charges that have passed coding review are scrubbed against payer and format rules.
3. Clean claims are submitted electronically, usually each business day.
4. Acknowledgments and rejection reports are reviewed. Errors are fixed and claims resubmitted.
5. Accepted claims are tracked until the payer processes them, then handed to payment posting and follow-up.
6. You receive regular reports on volume and rejection reasons, with advice on fixing root causes.

Common challenges

• Front-end rejections. Claims can be turned away before the payer sees them for bad member IDs, missing data, or format errors. An experienced biller reads rejection reports daily and fixes the cause, not just the claim.
• Claims that vanish. A claim may be accepted by the clearinghouse but never reach the payer. Billers match submissions to acknowledgments and check status when a claim stalls.
• Payer-specific rules. Each payer has its own quirks on modifiers, billing provider data, and attachments. Billers keep payer notes and update scrubber rules.
• Provider enrollment mismatches. A claim can fail if the billing or rendering provider is not set up with that payer. Billers flag these and work with credentialing.
• Filing limits. Payers set deadlines for first-time claims. Medicare generally allows one calendar year from the date of service, and many commercial payers allow less. Billers track deadlines and prioritize older claims.
• Secondary and coordination of benefits. Claims sent to the wrong payer first get denied. Billers confirm coverage order before submitting.
• Clearinghouse changes. Moving to a new clearinghouse can interrupt payer enrollment. Billers plan the transition to avoid gaps.

Metrics worth tracking

• Clean claim rate: share of claims accepted on first submission; shows data quality.
• First-pass acceptance by payer: highlights payers or edits that cause the most trouble.
• Rejection rate and top reasons: shows which errors to fix at the source.
• Days from service to submission: shows how quickly claims go out.
• Unsent or held claims: claims waiting on a fix; a growing number signals a bottleneck.
• Claims nearing filing limits: protects revenue from timely filing denials.

Codes and standards

Code or standard	Type	What it covers
837 Professional (005010X222)	EDI transaction	Electronic claim format for professional services
837 Institutional (005010X223)	EDI transaction	Electronic claim format for facility and institutional services
837 Dental (005010X224)	EDI transaction	Electronic claim format for dental services
276/277 (005010X212)	EDI transaction	Claim status request and response
835 (005010X221)	EDI transaction	Payment and remittance advice returned after processing
CMS-1500	Claim form	Paper professional claim form
CMS-1450 (UB-04)	Claim form	Paper institutional claim form
42 CFR 424.44	Regulation	Medicare's general rule on the time limit for filing claims

Note

Codes and standards are examples for orientation, not a complete list, and do not guarantee coverage or payment. Always check current code sets and payer policy.

Specialties that use this service

• Family Medicine
• Physical Therapy
• Psychiatry
• Durable Medical Equipment
• Hospitals
• Dermatology
• Home Health Agencies

How Westmont can help

• We match you with vetted billing experts experienced in claims submission and clearinghouse work.
• We look for teams that work in your practice management system or can work with your clearinghouse.
• We help you find providers familiar with your payers and claim types.
• We start with a conversation about your rejections and backlog so the match fits.

Frequently asked questions

What does a clearinghouse do?

A clearinghouse receives claims from your billing system, checks them for format and data errors, and routes them to the correct payer. It also returns acknowledgments and rejection reports. Think of it as a mail sorter with a basic proofreader. It does not decide whether a claim will be paid.

What is the difference between a rejection and a denial?

A rejection means a claim was turned away for a data or format problem before the payer accepted it for processing. You fix it and resubmit. A denial happens after the payer processes the claim and decides not to pay. Denials usually need an appeal or a corrected claim.

How fast should claims go out?

As soon as charges are coded and clean. Most practices aim to submit daily. Waiting makes errors harder to fix and risks missing payer filing limits. A claims submission company can run a daily process and report on anything held back.

Can I keep my own clearinghouse?

Often yes. Many billing experts work inside the clearinghouse you already have. Others have their own connections. Ask any provider how they handle payer enrollment, rejection reports, and access to your data if you ever change vendors.

What happens to rejected claims?

A biller reviews the rejection reason, corrects the data, and resubmits. If the cause is systemic, such as a bad payer ID in your software, they fix the source. Good providers also report on rejection patterns so fewer claims bounce in the future.

Related services

• Charge Capture
• Medical Coding & Coding Audits
• Payment Posting & Reconciliation
• Denial Management & Appeals
• Eligibility & Benefits Verification
• Credentialing & Payer Enrollment