Clearinghouse Basics
A clearinghouse is a centralized computer entity
that receives claims from providers, validates and customizes those
claims for the various carriers, then submits them to the
appropriate insurance carriers.
All insurance carriers must accept electronic
claims. Many are large enough that they have their own
submissions structure and claims are submitted directly to them.
Others may require the use of a specific agency to accept their
claims. In all cases, the submitter must be registered
for the carrier and electronic claims must be tested and validated
prior to submissions being accepted from that submitter.
As an ambulance provider, it is typically
impractical to submit electronically to a variety of carriers on
your own. Some states provide software that can be used to
submit directly to their Medicare or Medicaid carriers. These
systems can work well for the claim submissions, but they have no
ability to track accounts receivable, produce invoices, track past
dues, or submit claims to other carriers. This results in the
provider having to double-enter the information into another program
in order to perform the necessary accounting tasks and to print-out
or submit claims to other carriers.
A clearinghouse serves as a technical
"middle-man" by accepting claims in a standardized manner, then
customizing them for the specific carriers before submitting them.
The registration, testing and technical headaches of submitting to
multiple carriers is performed by the clearinghouse.
If the billing software produces an acceptable
electronic claim output file, the provider can submit to multiple insurance carriers through
a clearinghouse without double entry of data and without multiple
registrations and submission requirements.
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