What Is Claim Submission Process in Medical Billing?

A healthcare provider may deliver and document a service correctly, but reimbursement still depends on submitting an accurate claim and following it through the payer’s review. The claim submission process in medical billing is how providers request payment from insurers for services delivered to patients, and it relies on accurate documentation, medical coding, and complete patient information working together.

When any of those pieces is off, claims can be rejected, denied, or paid late. Incomplete patient details, coding errors, and payer-specific requirements are common causes. This guide explains claims submission in medical billing step by step, shows how electronic claims move through the medical claims process, covers what happens after submission and the problems that most often get in the way, and explains what affects how long medical claims take to process.

What Is Claim Submission in Medical Billing?

Claim submission in medical billing is the process of preparing and transmitting a healthcare claim to an insurance payer to request reimbursement for covered services. The claim includes patient, provider, service, diagnosis, procedure, and charge information.

It is one stage of the broader revenue cycle management process, not the whole medical claims process. Before submission, practices handle patient registration and insurance verification, clinical documentation and charge capture, and medical coding and claim preparation. After submission come payer acknowledgment, adjudication, payment posting, and follow-up. Submission is the act of sending the claim. It does not mean the payer has accepted it for adjudication or approved it for payment.

Two claim categories are common. Professional claims are generally submitted by physicians and other non-institutional professionals, and the standard electronic format is the 837P. Institutional claims are generally submitted by hospitals and other institutional providers, using the 837I. The CMS-1500 and UB-04 paper forms are associated with professional and institutional billing, respectively. Electronic formats and paper forms are related, but they are not interchangeable concepts.

Providers commonly submit claims electronically, either through a clearinghouse or directly to a payer using an approved connection or portal. Electronic submission is common because it supports faster transmission and automated validation. Whichever route a practice uses, the claim should leave the office only after it has been checked against the documentation, because errors caught before submission are far cheaper to fix than errors found after a rejection.

How Does the Claim Submission Process Work Step by Step?

These six steps follow a claim from the front desk to the payer. Exact workflows vary by payer, clearinghouse, software, and submission method, but the sequence stays largely the same.

Step 1: Verify Patient Information and Insurance Coverage

Start by confirming the patient’s name, date of birth, and identification details, along with insurance member and group numbers and coverage status on the date of service. If the patient has more than one plan, note primary and secondary coverage, and check whether a referral or prior authorization applies. Front-desk staff usually collect most of this information at scheduling or check-in, so consistent registration habits make everything downstream easier. These checks help surface coverage issues, but they do not guarantee payment. 

Step 2: Complete Clinical Documentation and Charge Capture

The provider’s documentation establishes what services were performed and supports the charges entered into the billing system. Staff record the correct date of service, rendering provider, procedures, supplies, and applicable charges. Incomplete or inconsistent documentation can create problems during coding, claim review, or payer adjudication, so billing information should always reflect the services documented in the medical record.

Step 3: Assign Medical Codes and Prepare the Claim

Medical coding translates diagnoses, procedures, and services into standardized codes: ICD-10-CM for diagnoses, CPT for many professional procedures and services, and HCPCS Level II for applicable supplies, equipment, and services. The claim also needs modifiers, place-of-service information, provider identifiers, and any payer-specific data. Professional and institutional claims require different data and formats, and every code must be supported by the medical record and applicable coding guidance. 

Step 4: Scrub the Claim Before Submission

Claim scrubbing is a pre-submission review that looks for missing fields, inconsistent information, coding issues, and other potential errors. Teams check patient and subscriber details, billing and rendering provider information, diagnosis and procedure combinations, required modifiers, payer-specific rules, and potential duplicate claims. Scrubbing software can flag issues, but billing staff still have to investigate errors and use the documentation to resolve coding or medical necessity questions. The goal is to send a clean claim the first time.

Step 5: Submit the Claim Electronically

There are two common routes. Through a clearinghouse, the provider sends claims to an intermediary that performs applicable validation and forwards them to the payer. Directly to the payer, the provider uses the payer’s designated portal or electronic connection, where available. Both rely on the 837 electronic claim transaction, with different versions for professional and institutional claims. Electronic submission reduces manual handling, but it does not remove the need to check acknowledgments and resolve errors. Practices that want help with this stage can explore our medical billing services.

Step 6: Check Claim Acknowledgments and Correct Errors

Submitting a claim is not the final step. Electronic workflows return several transactions, and each says something different.

An acknowledgment is not approval or payment. If a claim is rejected, staff should identify the reason, correct the issue, and resubmit when appropriate. Accepted claims should keep being monitored until the payer issues a determination.

Timing matters as well. Submit claims promptly after the service is documented and coded, rather than holding them in a batch, so there is time to correct rejections before filing deadlines. Keep a simple log of submission dates, acknowledgments received, and follow-up actions for each claim.

What Happens After Medical Claims Are Submitted?

Submission and processing are different things. Once a claim leaves the practice, the payer’s side of the work begins.

Initial validation. Electronic submissions undergo applicable checks. Some errors cause a file or individual claim to be rejected before it reaches the full payment review.

Adjudication. The payer evaluates the claim under its coverage policies, benefit terms, coding rules, medical necessity requirements, and provider contract terms. The outcome may be full payment, partial payment, denial, or another determination, depending on the circumstances.

Payment and remittance. The ERA shows payments, adjustments, and any remaining patient responsibility, which billing teams use to post payments and reconcile accounts. Reviewing each remittance line by line helps staff see whether an adjustment was contractual, whether a denial needs correction, and what the patient may owe. Balances that move to the patient are handled through patient billing services.

Rejected versus denied. A rejected claim generally has an error that prevents it from moving through the intended workflow. A denied claim has been adjudicated, but payment has been refused in whole or in part. Terminology and workflow vary by payer, so staff should follow the payer’s own explanation and instructions.

Follow-up and appeals. Unresolved claims may need status inquiries, corrected submissions, additional documentation, or an appeal, depending on the reason and the applicable rules.

What Are the Common Claim Submission Problems, and How Can Providers Prevent Them?

Inaccurate patient or insurance information. Incorrect member IDs, outdated insurance details, or subscriber errors can interrupt processing. Consistent registration procedures and insurance verification reduce these problems.

Coding and documentation discrepancies. Mismatches between documented services and submitted codes, missing modifiers, and incomplete supporting records are common. Regular coding reviews and staff training help, and our beginner’s guide to medical coding is a useful refresher.

Missing authorizations or referrals. Some services and plans require them. Confirm requirements early and, where feasible, before services are delivered.

Incorrect payer routing or submission details. Choosing the wrong payer, or using incorrect provider identifiers or submission settings, can lead to rejections or delays. Payer IDs and submission settings change from time to time, so periodic review helps.

Missed filing deadlines. Timely filing limits vary by payer, contract, and claim circumstances, so practices should track the deadlines that apply to them rather than rely on one universal timeframe. Tracking deadlines by payer in the billing system or a shared calendar prevents last-minute scrambles.

Failure to monitor claim status. Review acknowledgment reports, work rejected claims promptly, track unresolved claims, and document every follow-up. A trained billing specialist typically owns much of this work.

A standardized workflow, trained staff, reliable billing software, and regular performance reviews help practices spot recurring problems. These steps support better claim management, but they cannot guarantee reimbursement. Some practices also consider outside support, and our overview of what a medical billing company does explains what to compare.

Final Thoughts

The claim submission process in medical billing is central to revenue cycle management. Accurate patient information, complete documentation, appropriate coding, pre-submission checks, and consistent claim tracking all contribute to a more organized workflow. Submission is only one stage, since billing teams must also monitor payer responses, resolve rejections, review adjudication outcomes, and reconcile payments. A structured process helps practices manage claims more effectively, reduce avoidable rework, and keep visibility into outstanding claims.

Frequently Asked Questions About Medical Claim Submission

How to Process Medical Claims?

The general workflow is to verify patient and insurance information, review documentation, assign supported codes, prepare and scrub the claim, submit it to the correct payer, check acknowledgments, and follow up until the payer issues a determination.

How Long Do Medical Claims Take to Process?

There is no universal answer. Processing time varies by payer, claim type, submission accuracy, and whether extra information or review is needed. Time spent correcting a rejection or resolving a denial is separate from the payer’s processing time. Check each payer’s claim-processing policies and any applicable contractual or regulatory requirements.

What Is the Difference Between Claim Submission and Claim Processing?

Submission is transmitting the claim. Processing is the payer’s review and determination. A successful transmission does not mean the claim has been approved for payment.

What Happens If a Medical Claim Is Rejected?

The billing team should review the rejection information, correct the underlying issue, and resubmit the claim according to the payer’s instructions and applicable deadlines.