What is Claims Submission Software?

Claims Submission Software is a specialized application that formats, organizes, and securely transmits healthcare claims (837 EDI files) from the healthcare provider to the payer or to an intermediary Financial Clearinghouse.

In the context of RCM automation, the submission functionality is typically integrated into the RCM platform, acting as the final checkpoint and outbound gateway for the data verified and scrubbed in the preceding phases of the revenue cycle.

Why Claims Submission Software is Critical for CFOs and Financial Leaders

The quality and intelligence of the submission process directly affect Cash Flow Velocity and Compliance Risk.

• Ensuring EDI Compliance: Automated submission software ensures the claim format adheres strictly to the required Electronic Data Interchange (EDI) standards of the target payer, drastically reducing rejections that halt the revenue cycle.
• Proof of Timely Filing: The software provides an auditable trail of when the claim was sent and accepted by the clearinghouse or payer, protecting the organization against timely filing denials, which are otherwise unrecoverable.
• Maximizing Clean Claim Rate (CCR): By performing final, real-time scrubbing checks upon submission, the software prevents costly last-minute errors from reaching the payer's adjudication system.

Key Use Cases: Automation at the Submission Point

Modern RCM platforms automate the entire submission process:

• Batch and Real-Time Submission: Claims are batched for efficiency, but critical claims (like those nearing the timely filing deadline) can be submitted instantly.
• Status Tracking Integration: The software automatically receives and processes initial acceptance or rejection reports from the clearinghouse/payer, immediately triggering Denial Management workflows if an issue arises.

Claims Submission Software vs. Billing Service

This is often a choice between technology ownership and outsourced labor:

• Claims Submission Software (Integrated): Provides the provider with direct technological control and transparency over the submission process, leveraging AI/RPA for efficiency.
• Billing Service: Outsourced labor that manually handles submission and follow-up, often providing less real-time insight or control over the process.

Resources and Education

• Candid Health Solution: Platform Overview /solution
• Product Claims: Claims Submission Capabilities /product/claims