RCM

Steps of RCM

1. Appointment Scheduling

   • Patient books appointment via call or online.

   • Helps manage provider availability and avoid wait times.

2. Eligibility & Benefits Verification

   • Verify patient’s insurance eligibility and covered benefits.

   • Confirm via payer websites or patient’s insurance card.

   • Essential even for returning patients (policy may change).

3. Registration & Pre-Encounter

   • Collect patient documentation, consent, financial responsibility forms.

   • Obtain any required authorizations, ensure availability of instruments / reports before service.

4. Encounter (Service Delivery)

   • Provide the actual clinical services.

   • Record details (via dictation, notes) for later use in documentation and coding.

5. Medical Transcription

   • Convert voice dictation or recorded notes into formal medical records.

   • Ensures accurate written record for coding and billing.

6. Medical Coding

   • Coders assign appropriate CPT (procedure), modifiers and ICD-10 (diagnosis) codes based on records.

   • Accurate coding reduces rejection/denial risk and speeds reimbursements.

7. Demographic & Charge Entry

   • Enter patient demographics and coded charges into a Practice Management System (PMS).

   • Accuracy is critical to avoid clearinghouse or payer rejections.

8. Claim Submission

   • Send claims to payer using forms (CMS-1500 for physician claims, UB-04 for hospital claims).

   • Claims include all required provider, patient, and service details.

9. PMS Scrubber / System Scrubber

   • Automated validation of formatting and field rules before claim leaves the system.

   • Detects errors (e.g. invalid number formats) for correction before submission.

10. Clearing House & Payer Rejection Screening

    • Clearinghouse validates and may reject claims before passing to payer.

    • Then payer runs its own checks — claims may be rejected due to eligibility, provider enrollment, payer ID, etc.

11. Insurance (Payer Processing)

    • If accepted, insurer reviews claim and issues either payment or denial.

    • Generates EOB (Explanation of Benefits) or ERA (Electronic Remittance Advice) documents.

12. Payment Posting

    • Provider posts payment or denial details from EOB/ERA into system.

    • If EOB/ERA not received, team may retrieve via payer website.

13. Accounts Receivable (AR) Follow-Up

    • AR team investigates missing or unclear payments.

    • Contact payer to clarify or recover outstanding amounts.

14. Denial Management

    • Analyze claims denied or partially paid and identify reasons.

    • Take corrective actions: resubmit, appeal, correct coding or provider enrollment, etc..

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