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By Gregg Opper, PatientClick Staff

Medical billing clearinghouses forward electronic claims from healthcare providers to insurance payers. Normally they send the electronic format of the CMS 1500 form also known as the 837p or the electronic form of the UB-04 also known as the 837i. They can also send back information from the insurance payer such as the 835 remit (tells you what is being paid). This back-and-forth between providers and payers is the main service of the clearinghouses.

Each clearinghouse has to setup a relationship with each insurance payer and the healthcare provider (and their billing software).

Medical billing clearinghouses also may provide other useful services to healthcare providers and their staff. Many provide eligibility checks so that patient coverage can be verified before a patient is seen. The quality of information that clearinghouses provide in eligibility checks can vary and can depend to a degree on how often and what information they can get from the insurance payer.

Additional services provided by clearinghouses may include reports and web interfaces where medical billing staff can get much more information on claims, rejections, etc.

Clearinghouses normally charge a fee either based on per claim, per eligibility check, per provider, by services being used, or some combination.

On the technical side, clearinghouses conform to HIPAA guidelines and use Electronic Data Exchange X12 protocal for the transmission of data. These transmissions use established data forms:

  • EDI Health Care Claim Transaction Set (837),
    • 837i for institutions (UB-04 equivilant)
    • 837p for professionals (CMS 1500 equivilant)
  • EDI Health Care Claim Payment/Advice Transaction Set (835),
  • EDI Benefit Enrollment and Maintenance Set (834),
  • EDI Health Care Eligibility/Benefit Inquiry (270), and
  • EDI Health Care Claim Status Request (276).
Though the forms are standarized, the information within the fields on those forms may vary between medical billing clearinghouses. What they require, etc.

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