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 after you post charges into PCC EHR.

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 Electronic Encounter Form.

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 is a record of charge information.

You create claim tags in other ways, too. When you correct a problem on a charge (in Correct Mistakes(oops)), you may generate a new claim, which creates a claim tag. When you post payments and adjustments, the Post Insurance Payments (pip) program creates tags for the next responsible party.

PCC Processes the Claim and Sends it to the Payer

How does PCC transform the tags on your system into claims? Your practice runs Prepare Claims (preptags) to kick off the process. Alternatively, you could use the hcfa program to print paper HCFA claims for any batch (a batch is a collection of tags).

When your practice runs Prepare Claims (preptags), PCC’s practice management engine sorts the tags, checks for errors, puts designated tags into a paper batch 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. The payer reviews the claim and sends payment, adjustment, and rejection details back through PCC and into your inbox.

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 1-1-800-722-7708.

Under the Hood Vocabulary: When you speak with PCC’s interoperability teams, you may hear references to preptags, tagsplit, and splitconfig. These are the 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 file. The preptags program then 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 interoperability 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
  • Provider 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 your client advocate. PCC also hosts free interactive web labs where you can ask billing, coding, and practice management questions.

  • Last modified: August 26, 2021