Your Fastest Path to Reliable Payments Starts with Accurate Claim Submission

Claim submission is not just another step in the revenue cycle, it’s the one that determines whether your medical practice gets paid on time or not at all. The claim submission process includes sending a claim with correct code to an insurance. It sounds simple, but it can get complicated quickly.

For physicians, therapists, and practice managers, errors in this process are one of the main reasons for delay in payments. If there are continuously mistakes in coding, patient details, or payer-specific rules, these small mistakes can turn into weeks or months of lost revenue.

Pro-MedSole RCM handles claim submission for providers across the U.S., and we’ve seen how easily small errors snowball into denied claims. But with the right process and team in place, you can drastically improve your clean claim rate.

The Claim Submission Process Step-by-Step

1. Patient Data Collection

The submission process starts from the moment a patient schedules an appointment. Their demographic details, insurance information, and reason for the visit must be captured accurately. Any mismatch later like the wrong policy number or misspelled name can cause claim rejections.

2. Insurance Eligibility Verification

Before the claim is ever submitted, eligibility verification ensures that the patient is actually covered for the services provided. This also includes checking for prior authorization requirements or service limitations.

3. Accurate Medical Coding

CPT, HCPCS, and ICD-10 codes are essential in telling the payer what was done, why it was done, and how long it took. The errors in medical coding like mismatched diagnosis and issues in procedure codes may results in denials.

4. Claim Creation

Once coding is done, a claim is generated with all required fields. This includes provider details, NPI numbers, tax ID, location, and rendering provider info. Even one incorrect digit in this section can hold up payments.

5. Internal Scrubbing

Before a claim is sent to a clearinghouse or payer, it should go through a scrubbing tool or quality check. This step flags missing information or formatting issues that could result in an automatic rejection.

6. Submission to Clearinghouse or Payer

Depending on the payer, the claim is sent electronically through a clearinghouse or directly to the insurer. Each payer may have unique format requirements or data expectations.

7. Claim Tracking

Submission doesn’t end with sending. It’s crucial to track claim status with clearinghouses and payers. This ensures quick follow-up if a claim goes missing or stalls in processing.

Common Claim Submission Issues Practices Face

Even the most organized practices face issues in claim submission. Here are a few that we regularly see:

• Duplicate claims due to miscommunication between billing and front desk
• Missing modifiers for services like telehealth or bilateral procedures
• Unverified insurance coverage due to outdated eligibility info
• Expired CPT codes or unlisted services
• Incorrect place of service (POS) codes
• Payer-specific format violations

At Pro-MedSole RCM, we manage these risks with structured billing workflows that double-check every field before submission.

How Payer Rules Affect Claim Submission

Not every insurance payer works the same way. Some payers reject claims without a rendering provider ID. Others demand separate claims for certain procedures. Understanding payer-specific expectations is key to timely payments.

Here’s a quick example:

• Medicare often requires extra documentation for psychotherapy over 60 minutes.
• Medicaid rules differ between states and may need T-codes for behavioral services.
• Private insurers may require electronic attachments for certain injections or infusions.

Payer variability is why Pro-MedSole RCM maintains custom billing rules by payer profile, so each submission aligns with their system.

Improving Clean Claim Rate: What Really Works

A “clean claim” is one that passes all payer and clearinghouse checks without needing edits or resubmission. Most practices aim for a clean claim rate above 95%, but many fall short. As AMA is helping medical practices handle claims processing.

What makes a claim “clean”?

• Correct CPT and ICD-10 combinations
• Verified insurance eligibility
• Up-to-date provider information
• Proper use of modifiers
• No missing demographic data

At Pro-MedSole RCM, our approach to clean claim submission includes:

• Pre-submission scrubbing
• Dedicated QA teams for coding review
• Automated alerts for outdated or incorrect payer data
• Live tracking dashboards for claim status
• Feedback loops to front office teams on recurring errors

The Financial Impact of Submission Errors

Errors in claim submission have a direct impact on your revenue. Consider the following:

• Each rejected claim costs an average of $25–$30 to rework (source: MGMA).
• Up to 25% of denied claims are never resubmitted, meaning lost income.
• Average rework time is 15–30 minutes per claim, draining staff resources.

If your practice is dealing with high denial rates, delays, or partial payments, chances are the submission process needs attention.

How Pro-MedSole RCM Supports Smooth Claim Submission

At Pro-MedSole RCM, claim submission is more than pushing a button, it’s about securing revenue. We handle the entire journey, from charge entry to clean claim creation and payer-specific routing.

We also provide:

• Daily claims tracking
• Error rate monitoring
• Quick resolution on rejections
• Direct payer follow-ups
• Reporting on submission success and denial trends

Final Thoughts

Claim submission may look easy task, but it’s mostly where revenue leakage begins. Whether it’s a missing field or an outdated code, small mistakes result in delayed reimbursements and disturb cash flow.

Outsourcing your claim submission process to a dedicated medical billing partner like Pro-MedSole RCM gives you peace of mind, time savings, and more revenue coming in not stuck in limbo.

Let us help you send clean claims, reduce denials, and improve financial outcomes for your practice.

Need support with claim submission?
Contact Pro-MedSole RCM today to schedule a free revenue assessment.