Electronic medical clearinghouses are an important facet of the entire medical coding and
billing process and cycle. Clearinghouses take medical claims information and screen them for accuracy before they
electronically submit them to the health insurance companies they are contracted with. They function as a hub, a
middle man so to speak, to streamline the process. If the clearinghouse software catches errors
made in a claim they let you know instantly where the mistake was made so it can be corrected. This procedure
dramatically decreases the time it takes to process a claim, often under 10 days. When you sign a
contract with one of the many medical billing clearinghouses offering their services, your preferred
clearinghouse should provide you with an extensive payer list to choose from and should be nationwide, not
Steve Verno said: "Now, speaking of clearinghouses, as I stated, your software may allow
you to send your claims file to random clearinghouses and it may restrict you to one clearinghouse of the software
So MANY Clearinghouses! Now I Am Confused...
By Steven M. Verno, CMBS, CEMCS, CMSCS, CPM-MCS
There are also many clearinghouses out there. Some examples I've seen are ANS, Availity,
Emdeon, Ingenix, Proxymed, and Zirmed. I do not endorse any of these companies. I have worked with Availity and
Zirmed and liked both. When using a clearinghouse, your billing software creates an electronic file of claims you
send to an insurance company. The file is sent to the clearinghouse. The clearinghouse scrubs the
file for errors and distributes your claims to the insurance company that the clearinghouse contracts with to send
claims to. Each clearinghouse has a list of insurance companies, also called a payor list they send claims directly
For example: ABC Clearinghouse lists Aetna, Blue Cross, Cigna, Humana, Medicare and Medicaid.
If you need a claim to go to Aetna, you will set up your billing software to show Aetna as an electronic claim
using an electronic number for Aetna supplied by the clearinghouse. For example Aetna may have number N3562 (Made
Up Number). This number is called an NEIC payer number. The clearinghouse should be able to
provide you with a payer list before you sign a contract with them. Your software may process electronic claims
first and paper claims second.
EXAMPLE: Let's say you need a claim to go to Sunrise insurance. ABC Clearinghouse does not send
claims to Sunrise. You do not set up Sunrise as an electronic insurance. You can print the claims
yourself, or you can contract with the clearinghouse to print and send them for you, naturally at a cost to you.
Some insurance companies may allow you to send claims directly to them via their website, but this may be
reserved for doctors that are contracted with the insurance company. When doing this you need to find out how
you will know whether the claims were received, because some do not provide anything to confirm this. You
later find out the claims were not on file. Its always important that you verify, verify, verify everything.
Dealing with Clearinghouses
When using a clearinghouse, there will be a contract for your to review and sign. Some
clearinghouses want a set up fee. Lets say ABC Clearinghouse charges a $500 set up fee per provider. You have 3
providers, your set up fee is going to be $1,500. This is before You send any claim. Some clearinghouses also
charge you on a per claim basis. This can be anywhere from $2.00 to $10 per claim. It varies, so ask for all
expenses ahead of time. When You contract with a clearinghouse, make sure You get a report showing the claims were
received by the clearinghouse. Also ask for a report showing that the insurance company received the claim.
REMEMBER: There is nothing worse than checking the status of your claim
and finding out the insurance company says it is not on file.
You also want to have your contract specify what happens when the insurance company denies receipt of the claim.
I made the clearinghouse contact the insurance company or resend the claim for free. But, I wanted them to work
with the insurance company. The receipt reports were helpful when I contacted the CEO of the insurance company and
the regulatory authorities for a possible violation of State insurance laws. Make sure your contracts are specific,
that they address your needs, that they address resolution issues, and they work for you. As always, have contracts
reviewed by an attorney for your protection. -- Steve Verno, Certified Biller (My
Medical Billing Community Forum)