RCM Steps

Appointment Scheduling

• Patient books appointment via call or online.

• Helps manage provider availability and avoid wait times.

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).

Registration & Pre-Encounter

• Collect patient documentation, consent, financial responsibility forms.

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

Encounter (Service Delivery)

• Provide the actual clinical services.

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

Medical Transcription

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

• Ensures accurate written record for coding and billing.

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.

Demographic & Charge Entry

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

• Accuracy is critical to avoid clearinghouse or payer rejections.

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.

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.

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.

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.

Payment Posting

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

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

Accounts Receivable (AR) Follow-Up

• AR team investigates missing or unclear payments.

• Contact payer to clarify or recover outstanding amounts.

Denial Management

• Analyze claims denied or partially paid and identify reasons.

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