Claims
Claim scrubbing
A claim is checked twice. The scrub report, shown when the claim is built, lists what a payer is likely to reject but does not stop anything. The 837P validation, run when the claim is submitted, refuses to send a claim that cannot be built correctly.
Written for: Billing and RCM teams
Two checks, two jobs
| Field or control | What it means |
|---|---|
| Scrub report | Runs once, automatically, right after Build Claim. Returns pass or fail, a score out of 100 and the findings. Advisory: the claim exists whatever the report says, and nothing stops you submitting it. |
| 837P validation | Runs every time Submit to clearinghouse is pressed, before anything is transmitted. A claim that fails is refused with the reasons, stays Pending, and nothing is sent. |
What the scrub report checks
| Field or control | What it means |
|---|---|
| Patient (PAT) | Name and date of birth present; address complete; ZIP code format. |
| Insurance (INS) | Member id and payer id present; group number present. |
| Provider (PRV) | Rendering and billing provider NPIs present and well formed; tax id present. |
| Diagnosis (DX) | A primary diagnosis present; ICD-10 format. |
| Procedure (CPT) | Procedure code present and CPT/HCPCS-shaped; charge amount above zero; units valid. |
| Dates (DATE) | Service date present, not in the future, not before the date of birth; a warning when the service is more than 90 days old (a fixed threshold - payer timely-filing limits recorded on Payers are not used). |
| Billing (BILL) | Billed amount above zero; place of service present and valid. |
The score starts at 100 and loses 25 for each critical finding, 10 for each high, 5 for each medium and 2 for each warning. It is a reading aid, not a prediction of payment.
What actually blocks submission
| Field or control | What it means |
|---|---|
| No lines | The claim has no charge lines (or a secondary claim names no primary). |
| Missing diagnosis | A line has no diagnosis to point at. |
| Missing member id or payer id | The coverage on the claim does not record them. |
| Subscriber not the patient | A dependent's claim without the policy holder's first and last name on the coverage. |
| Total mismatch | The sum of the lines does not equal the claim's stored total. |
| No active facility | No billing facility (NPI, taxonomy, address) is configured. |
| Billing facility ambiguous (AMBIGUOUS_BILLING_FACILITY) | Several facilities are active and the claim's visits do not name exactly one of them. Deactivate the facilities that do not bill, or record the facility on the visits. |
| Replacement without payer claim number | A corrected claim must quote the payer's own claim number. |
| No claim filing indicator (MISSING_FILING_INDICATOR) | The payer (or, for a secondary, the primary claim's payer) has no claim filing indicator and its payer type does not imply one. Set it on Settings → Payers. |
| Rendering clinician without NPI (MISSING_RENDERING_NPI) | A line's rendering clinician has no valid NPI on file (Settings → Clinician billing). |
| Prior authorization (MISSING_AUTHORIZATION, MULTIPLE_AUTHORIZATIONS) | A line consumed an authorization with no number on record, or the lines consumed more than one authorization. A never-sent claim can be split into one claim per authorization from the Claims list. |
| Secondary without primary adjudication (MISSING_PRIOR_PAYMENT) | A line of a secondary claim has no record of how the primary payer adjudicated it. |
| No submitter contact | The clearinghouse mailbox settings have no submitter contact phone or email (required in the 837 header, 1000A PER), so every claim is refused. |
| Too many diagnoses (TOO_MANY_DIAGNOSES, TOO_MANY_POINTERS) | More than 12 diagnoses on the claim, or more than 4 on one line. |
| No place of service (MISSING_PLACE_OF_SERVICE) | A line has no place of service and the billing facility names none. |
| X12 structure | Envelope, segment and element checks on the generated file. |