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837P & I EDI
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Claims Submission and Claim Scrubbing Services
Claims submission is scrub, transmit, and confirm acceptance into the payer’s adjudication queue — not the same as getting paid. Vector Medical Billing runs edit checks on every line, sends 837P professional and 837I institutional claims through your clearinghouse, and works front-end rejections the same business day when the 277CA comes back. From Jamaica, NY, for all 50 states. *Typical target after charge entry has a complete charge — not a guarantee for every payer or hold.
After charge entry
Where claims submission sits in the cycle
Coding and charge entry build the lines. Scrubbing and submission send them. What happens after adjudication is denial management and A/R — not submission.
A claim that fails at the clearinghouse never entered adjudication. A claim that was accepted and then denied for medical necessity did enter adjudication. Fixing the first is submission work. Fixing the second is denial work on medical billing services.
Electronic first: X12 837P (CMS-1500 data) for professional claims and 837I (UB-04 data) for institutional. Paper is reserved for the rare payer that still requires it — not the default path.
Clean claim rate vs denial rate
Two metrics. Vendors blur them. They measure different points in the cycle.
Clean claim / first-pass acceptance
Clearinghouse and payer accepted the file into adjudication — no front-end rejection. Required fields present, valid codes, payer ID correct, auth pointer when needed. It does not mean the payer paid.
Denial rate
Measured on adjudicated claims — paid, partially paid, or denied with CARC/RARC. Medical necessity, bundling, and contract edits still produce denials after acceptance.
Why they are not inverses
High acceptance can coexist with high denials if clinical or auth mismatches were not caught in scrubbing. Vector does not publish a client clean-claim percentage. MGMA and similar aggregates on first-pass denials are labeled industry context, not Vector results.
Automated edits vs human review
The rule library catches the library. Edge cases still need a person.
Automated scrub
Completeness, code validity, NCCI pairs, MUE units, age/sex edits, duplicate claim control numbers, and many payer-specific rules run before the batch leaves. Critical failures hold the claim. Warnings get a human look.
Human exception review
Modifier sequencing, specialty bundling, auth-to-CPT match, and LCD/NCD edge cases the rule file still misses. A person decides hold vs release — not a forced auto-correct that ships a bad claim.
What claim scrubbing checks
Failures return to billing staff, not to the payer queue.
| Edit category | Examples scrubbed pre-submit | If missed |
|---|---|---|
| Patient & subscriber | Name, DOB, gender, address, subscriber ID, relationship | 277CA demographic rejections; registration denials |
| Payer routing | Payer ID, plan type, COB order, crossover flags | Wrong payer; COB denials |
| Diagnosis | ICD-10-CM valid for DOS; pointer links procedure to diagnosis | Invalid DX edits; medical necessity at payer |
| Procedure codes | CPT/HCPCS active; age/gender edits when applicable | Front-end code rejections |
| NCCI / bundling | Column 1/2 pairs; mutually exclusive combos; modifier 59 / X{EPSU} when supported | Bundled line denials at adjudication |
| MUE | Medically unlikely edits on units per DOS | Unit denials |
| Modifiers | 25, 26/TC, 50, laterality, telehealth when documentation supports | Underpayment or modifier-specific denials |
| LCD / NCD | Medicare local and national coverage when configured for specialty | Medical necessity denials |
| Provider & POS | Rendering/billing NPI, taxonomy, place of service vs site | Provider mismatch rejections |
| Prior authorization | Auth number matches CPT, units, dates, site per prior auth | Precert absent (e.g. CARC 197) |
| Duplicates | Same patient, DOS, provider, and charge already in flight | Duplicate claim rejects |
| Timely filing | Days from DOS to submit vs payer limit | Timely filing denial with little appeal path |
| Institutional | Revenue codes, type of bill, occurrence codes on 837I / UB-04 | Institutional front-end rejects |
How claims are submitted electronically
Electronic first. Paper only when the payer still requires it.
1
Scrub
Rules engine plus human review on exceptions. Holds until required fields and edits pass.
2
Transmit
837 batch to your clearinghouse — Availity, Office Ally, Waystar, Change, or the vendor already on the account.
3
Acceptance
277CA acknowledgment parsed. Accepted claims move to pending payer status; rejects go to the workqueue.
4
Archive & track
Control numbers, batch ID, and submission timestamp stored for timely filing proof and payer follow-up.
Front-end rejections are not denials
A 277CA rejection never reached adjudication. Fixing it is still submission work.
Common clearinghouse rejects
Invalid payer ID, missing referring NPI, diagnosis pointer gaps, invalid procedure for age, duplicate claim control number, taxonomy mismatches, and auth field format errors. Each reject code maps to a fix in the PM — not a rebill guess.
Same-business-day rework
Rejections land in a workqueue the day the 277CA arrives. Corrected claims resubmit with a new control number when required. Chronic patterns feed back to coding and charge entry so the same edit does not repeat weekly. Timely filing is watched so a reject pile does not sit until the window closes.
Secondary claims and coordination of benefits
Secondary is not a copy of the primary claim with a different payer ID.
After primary adjudication
Secondary billing uses the primary remittance — allowed amounts, patient responsibility, and remaining COB — often from the 835. Scrubbing checks that primary paid or denied as expected and that CAS-style adjustments are reflected before the secondary file leaves.
COB still has to be right
Eligibility for the secondary plan should still be current when COB order was uncertain at registration — see eligibility verification. Secondary submission is part of full-cycle billing, not a separate product line.
Submission turnaround
Target is electronic submission within roughly 24 hours after a complete charge is available from charge entry — the same statement on the services index. Incomplete documentation, missing auth, or scrub holds extend that clock until the claim is scrub-ready. Turnaround is an operational target, not a contractual SLA published here.
How claims submission is priced
Scrubbing and 837 transmission on live claims are inside the full monthly billing fee — not priced per claim on standard engagements. Claims-only vendors sometimes quote per claim or per provider; that is market context, not Vector’s rate card. See medical billing pricing. Ask for a written rate.
Scrubbed claims through your clearinghouse
Tell us your PM, clearinghouse, and mix of 837P vs 837I. We confirm access and scope submission inside the billing engagement — no invented clean-claim percentage in the proposal.
837P
Professional
837I
Institutional
277CA
Reject Workqueue
50
US States
Claims submission questions
Straight answers tied to the sections above.
What is claim scrubbing?
Pre-submission validation of the claim — demographics, codes, NCCI, MUE, modifiers, auth match, and payer-specific rules — so fixable errors never hit the payer file.
What is a clean claim rate vs a denial rate?
Clean claim rate usually means accepted into adjudication without front-end rejection. Denial rate is measured after the payer adjudicates. High acceptance does not guarantee low denials.
Do you submit 837P and 837I?
Yes — professional and institutional electronic claims through your existing clearinghouse when the engagement includes those claim types. Paper only when a payer still requires it.
What happens when the clearinghouse rejects a claim?
The 277CA reject is worked the same business day when possible: fix in the PM, resubmit with correct control numbers, and log the pattern if it repeats. That is still submission — not a post-adjudication appeal.
How fast are claims submitted after charge entry?
Target is roughly 24 hours after a complete charge is ready. Holds for missing auth, documentation, or scrub exceptions extend until the claim passes edits.
Is claims submission an extra fee?
On the full monthly billing engagement, scrubbing and submission are included. Claims-only standalone work is quoted separately.
Do we change our clearinghouse or EHR?
No. Submission uses your current clearinghouse connection and practice management system — Athenahealth, eClinicalWorks, Tebra, AdvancedMD, DrChrono, NextGen, CareCloud, Practice Fusion, CureMD, Office Ally, or another path confirmed at onboarding.