Clearinghouse

An intermediary company that receives claims from providers, reformats them to meet each payer's specifications, scrubs them for errors, and transmits them to the correct payer.

A clearinghouse sits between your practice and the insurance payers. When you submit a claim from your EHR or billing system, it goes to the clearinghouse first. The clearinghouse validates the claim format, checks for common errors like invalid codes or missing information, reformats the claim to match the specific payer's requirements, and then transmits it to the payer. Think of a clearinghouse as a quality control checkpoint for your claims. Without one, you would need to submit claims directly to each payer in their specific format, which varies between payers. The clearinghouse handles that translation. Major clearinghouses include Change Healthcare (now part of Optum), Availity, Trizetto, Office Ally, and Waystar. Most EHR systems have partnerships with one or more clearinghouses, and the connection is usually built into the software. Clearinghouses also provide claim scrubbing, which catches errors before the claim reaches the payer. A good claim scrubber will flag issues like: invalid CPT or ICD-10 codes, mismatched procedure-diagnosis combinations, duplicate claims, missing required fields, and expired provider enrollment. Catching these errors before submission dramatically improves your clean claim rate. From a credentialing perspective, clearinghouses require your enrollment information to route claims correctly. When you credential with a new payer, you may also need to add that payer to your clearinghouse setup so claims get routed to the right place. If your clearinghouse does not have the correct payer ID, your claims will go nowhere. Clearinghouse fees are usually per-claim or per-transaction. Some charge monthly subscription fees with a certain number of claims included. The cost is a small fraction of what you save by having cleaner claims and faster submissions. If you are still submitting paper claims or submitting directly to payers, get on a clearinghouse. It will pay for itself immediately.