Billing Fundamentals/Foundation/18 minutes/Reviewed 2026-07-10
The Medical Billing Claim Lifecycle
Follow a claim from scheduling and eligibility through coding, submission, adjudication, payment, denial, and follow-up.
Quick answer
A reliable claim starts before the encounter. Eligibility, authorization, documentation, coding, claim edits, payer routing, remittance posting, and follow-up are one connected control system.
Rules to know
- Verify payer and benefit facts before service.
- Code only from supported documentation.
- Separate front-end rejection from post-adjudication denial.
- Use the ERA to route each balance to the correct next action.
Operational workflow
- 01Confirm demographics, payer order, eligibility, and authorization.
- 02Capture complete documentation and charges.
- 03Assign supported diagnosis, procedure, modifier, POS, and unit data.
- 04Scrub and submit the correct professional or institutional transaction.
- 05Reconcile acknowledgments, claim status, ERA, payment, and patient responsibility.
Common failure modes
- Treating a clearinghouse acceptance as payer acceptance.
- Working denials without reading all group, reason, and remark codes.
- Correcting one field without checking the rest of the claim context.
Knowledge check
Official sources
Electronic Health Care ClaimsCenters for Medicare & Medicaid ServicesReviewed 2026-07-10Medicare Claims Processing Manual (Publication 100-04)Centers for Medicare & Medicaid ServicesReviewed 2026-07-10Adopted Standards and Operating RulesU.S. Department of Health and Human ServicesReviewed 2026-07-10
Continue this track
Education only. Verify the current code set, payer contract, coverage policy, implementation guide, and claim-specific facts. Do not enter protected health information into this site.