What is claim scrubbing?
Claim scrubbing checks a claim against payer, coding and data rules before it's sent, so errors are fixed while they're cheap instead of coming back as rejections and denials.
Claim scrub results, claim CLM00433
| Check | Finding | Resolution |
|---|---|---|
| Eligibility | Coverage active on date of service | Passed |
| Authorization | MRI requires authorization; AUTH55120 on file | Number added to claim |
| NCCI | 29877 with 29881, same knee | Sent to coder |
| Rendering NPI | Missing | Filled from the provider record |
| Timely filing | Limit in 74 days | Passed |
- Four of five findings were fixed before sending. The NCCI question waits for a coder, not a denial.
Every rejection and many denials come from problems that were visible on the claim before it was sent. A scrubber looks for them first.
What a scrubber checks
- Data: patient and subscriber details, member ID, provider NPIs, place of service, dates.
- Coverage: active eligibility, authorization on file and covering the codes and dates, the right payer in the right order.
- Coding: valid codes and modifiers, NCCI pairs, MUE unit limits, diagnoses that support the procedures.
- Payer rules: each payer’s own requirements, from NDCs on drug lines to referral numbers.
- Clocks: how close the claim is to its timely filing limit.
Scrubbing is only half the job
Flagging an error doesn’t fix it. A scrubber that produces a long edit queue moves the work from denials to edits. The value comes from resolving findings automatically where the answer is in a record, and routing only the judgment calls to people.
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