Resources / Medical Billing Resources

How a claim gets paid.

The full journey of a US healthcare claim — registration to reimbursement — and the forms, IDs, and codes it passes through on the way.

The claim lifecycle.

Eight stages. A leak at any one costs money downstream — which is exactly where GetMax goes to work.

  1. 01

    Registration & eligibility

    270 / 271

    Patient demographics and insurance are captured, then coverage is verified electronically (270 inquiry → 271 response). Getting this right is what stops a claim from billing into a dead or wrong policy.

  2. 02

    Prior authorization

    Pre-service

    Where the payer requires it, approval is secured before the service. An auth that's missing — or doesn't match what was performed — becomes the payer's reason to deny later.

  3. 03

    Charge capture & coding

    ICD-10 · CPT

    Services delivered are recorded and translated into ICD-10-CM diagnoses and CPT/HCPCS procedures. The diagnosis has to support the procedure's medical necessity or the line won't pay.

  4. 04

    Claim creation & scrubbing

    837P / 837I

    Charges become a claim — professional (CMS-1500 / 837P) or institutional (UB-04 / 837I) — and run through edits that catch errors before submission. This is where first-pass clean claims are won.

  5. 05

    Submission via clearinghouse

    Clearinghouse

    The claim routes through a clearinghouse that validates format and forwards it to the payer. Format failures here surface as rejections — fixable and resubmittable before adjudication.

  6. 06

    Payer adjudication

    276 / 277

    The payer applies the member's benefits and its policies, then decides: pay, adjust, or deny. Claim status can be tracked electronically (276 inquiry → 277 response) while it's in flight.

  7. 07

    Remittance & payment posting

    835 / ERA

    The payer returns an electronic remittance (835 / ERA) explaining what it paid, adjusted, or denied per line. Posting and reconciling it is how underpayments and partial denials get caught.

  8. 08

    Denials, appeals & patient balance

    Denials · A/R

    Denials are worked and appealed before deadlines; remaining patient responsibility (copay, coinsurance, deductible) is billed. Aging accounts get A/R follow-up so earned revenue doesn't stall.

Two claims, two forms.

Which form a claim uses depends on who's billing — professional or institutional.

CMS-1500

837P (professional)
Billed by
Physicians, non-institutional & professional providers
Maintained by
NUCC — National Uniform Claim Committee
Typical use
Office visits, professional services, most physician billing

UB-04 (CMS-1450)

837I (institutional)
Billed by
Hospitals, facilities & institutional providers
Maintained by
NUBC — National Uniform Billing Committee
Typical use
Inpatient and facility/outpatient hospital billing

What every claim carries.

01

NPI

National Provider Identifier — the 10-digit ID (from CMS's NPPES) that identifies the rendering and billing provider on every claim.

02

Taxonomy code

The classification that states a provider's specialty. It has to align with what's billed, since payers use it in adjudication.

03

Place of service (POS)

A two-digit code for where care was delivered — e.g., 11 office, 21 inpatient hospital, 22 on-campus outpatient, 23 emergency room. The wrong POS shifts reimbursement or triggers denials.

04

Patient responsibility

What the member owes: a copay (fixed amount), coinsurance (a percentage), and the deductible met before the plan pays — all capped by the out-of-pocket maximum.

Reference structure only — always bill from current payer policies and the official CMS-1500 / UB-04 and code-set releases.

Keep reading
ICD resourcesKnowledge baseRevenue cycle FAQMedical billing service

Eight stages, one leak-free cycle. See it run on your claims.

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