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One claim, from exam room to reconciled cash. 1. Charge capture. Procedures become CPT/HCPCS (medical) or CDT (dental) codes plus ICD-10 diagnoses. Most “payer problems” start here. 2. Claim generation. The PM system builds an X12 837 (837P professional, 837D dental, 837I institutional). The clearinghouse validates, scrubs, and routes it. Rejections here bounce back in hours. The same error caught later as a denial costs weeks. 3. Adjudication. The payer checks eligibility, benefits, authorization, and policy, then prices each line at your contracted rate (the allowed amount) and decides: pay, reduce, deny, or pend. 4. Remittance and payment. The two artifacts travel separately: the remittance (835 or EOB) and the money (EFT, check, or virtual card). Reassociation rejoins them. Deductibles and coinsurance come back as patient responsibility. 5. Posting. Payments post, contractual adjustments write off, patient responsibility moves to the patient ledger, denials go to a work queue. Automatic with 835s, manual keying with EOBs. 6. Patient balances. With high-deductible plans this is a large share of revenue, and it collects far worse than payer receivables. The claim isn’t done until it’s collected or consciously written off. 7. Reconciliation. Every deposit explained by a remittance, every remittance’s money found in the bank. Posting without this is bookkeeping on the honor system.

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The clocks

Timely filing: payer contracts set submission deadlines, commonly 90 to 180 days; Medicare allows 12 months (CMS manuals). Miss it and the claim dies (CO-29). Appeal windows: each denial has its own deadline, per payer. Days-in-A/R measures how much revenue is stuck between steps 2 and 6.