The Claim Journey Explained

How is a claim created, and what happens in the background to make sure your practice is paid? Read below to learn some of the “under the hood” workings of claims with PCC.

You Post Charges and Create a Claim Tag

First, a clinician sees a patient. They create orders and enter diagnoses on the chart note, and they add billing details and select visit codes on the Bill screen in PCC EHR. (learn how)

Next, either the front desk or a biller reviews those diagnoses and procedures and posts them as charges. PCC queues up those charges and creates a claim tag, which indicates a collection of charges that are ready to be turned into a claim. (learn how)

You create claim tags in other ways, too. When you correct a problem on a charge, you might generate a new claim (in Correct Mistakes (oops)), which creates a claim tag. When you post payments and adjustments and a remaining balance pends the next responsible party, you create a new tag for a secondary claim (for example).

You Prepare and Submit Claims, PCC Sends Them to Payers

How does PCC transform these tags on your system into claims? Your practice uses the Claims tool (PCC EHR) or the Prepare Claims (preptags) tool in Practice Management to kick off the process. (learn how)

PCC sorts the tags, checks for errors, filters out claims that should be delayed or held, routes certain tags to paper when appropriate, and then launches the ECS service to send electronic claims to PCC for processing.

Claims travel through additional verification on PCC’s servers. Then we route them either directly to the payer or to a claim processing clearinghouse, which directs the claim to the payer. Your practice then uses the HCFA Claim Generation program to print any claims that needed to be submitted on paper (learn how), and reviews reports to fix any claims that needed corrections or were rejected by the payer.

Next, the payer adjudicates the claim. They send payment, adjustment, and CARC details back through PCC and into your system as an ERA (electronic remittance advice). You can post most ERAs automatically, and enter any denials or unusual responses manually. (learn how)

If you have any questions or would like to learn more about how claims are created in your office, feel free to contact PCC at 1-800-722-7708.

Under the Hood Vocabulary: When you speak with PCC’s EDI teams, you may hear references to preptags, tagsplit, and splitconfig. These are underlying programs that process claims according to your practice’s custom configuration needs. If you want to know the true nerdy side of what these words mean, the process works like this: PCC’s preptags program calls the tagsplit program according to your practice’s settings. The tagsplit program processes queued up tags and sorts them by insurance batch while doing a number of other validation checks, all of which relies on your practice’s custom configuration which is maintained in the splitconfig configuration. The preptags program automatically runs the ECS program, which submits claims to payers.

When PCC Processes Claims, What Claim Information Does it Review or “Scrub” for Errors?

When you process your claims, PCC reviews them for accuracy before submitting them electronically. This “claim scrubbing” results in cleaner claims, fewer claim rejections due to errors, and faster payment. What kinds of errors can PCC check for? What does it review before the claim is submitted? Here’s a recent list shared by PCC’s EDI specialists:

  • Patient first and last name
  • Patient date of birth
  • Patient Care Center assignment
  • Account (guarantor and custodial) names
  • Account address line, city, state, and ZIP
    • When a home is the place of service, PCC checks for the full ZIP+4 required by carriers
  • Account phone number
  • Patient / account relationship
  • Referring provider
  • Service date (relative to current date, patient date of birth)
  • CPT / HCPCS code (the claim processor checks your practice’s procedure code table to see that the codes on the claim are valid for the service date)
  • ICD-10-CM code (valid for service date; primary non-External Cause code)
  • Place of service address line, city, state, ZIP, phone number, and code
  • CARC values and charge / payment / adjustment balancing
  • NPI, tax identifier, and taxonomy code
  • Inpatient admission date
  • Practice address line, city, state, and ZIP
  • Pay-To Provider address line, city, state, and ZIP
  • Payor address line, city, state, ZIP, and [clearinghouse] identifier
  • Subscriber first and last name
  • Subscriber identifier
  • Subscriber group identifier
  • Subscriber date of birth
  • Subscriber address line, city, state, and ZIP
  • Original claim reference number
  • Accident state

PCC’s claim processing reviews all of the above and more.

For more information, or for help understanding why a claim can be rejected, contact PCC Support. PCC also hosts free interactive web labs where you can ask billing, coding, and practice management questions.

  • Last modified: November 28, 2022