Clearinghouse
An intermediary that receives claims from providers, scrubs them for errors, and forwards them electronically to the appropriate payer.
Clearinghouse Explained
A clearinghouse is an intermediary technology platform that receives claims from medical providers, scrubs them for errors, and forwards them electronically to insurance payers. It also routes EOBs and ERAs back to the provider for payment posting and reconciliation. Major US clearinghouses include Availity, Change Healthcare (now part of Optum), Trizetto Provider Solutions, Office Ally, Waystar, and athenahealth's network. The clearinghouse layer is where most pre-submission scrubbing happens — both standard format checks (HIPAA 837P/837I compliance, valid NPIs, valid taxonomy codes) and payer-specific edit packs that catch errors before the claim reaches the payer. A modern clearinghouse runs claims through 200+ scrubbing rules per claim, including NCCI PTP edits, MUE limits, payer-specific medical-policy edits, missing-modifier detection, and place-of-service mismatches. Choosing a clearinghouse is a meaningful operational decision — clearinghouses differ on payer connectivity (which payers they have direct connections versus routing through other clearinghouses), claim-status response time, EOB/ERA quality, edit pack depth, and pricing. Per-claim fees typically run $0.25-0.75 depending on volume and tier. The clearinghouse plus the team operating it determines the practice's clean claim rate as much as any other single factor.
See Also: Related Concepts
Clean Claim
A claim that passes all payer edits on first submission without errors. Clean claims get paid faster and cost less to manage.
CMS-1500
The standard claim form for professional (physician) services. Electronic equivalent is the 837P transaction.
UB-04
Standard claim form for institutional (hospital/facility) billing. Electronic equivalent is the 837I transaction.
ERA (Electronic Remittance Advice)
The electronic version of an EOB sent from a payer to a provider, used for automated payment posting and reconciliation.
EOB
Explanation of Benefits. Document from a payer showing what was billed, allowed, paid, and what the patient owes.
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