Why do some claims get rejected even when the billing information appears complete? What does an eClinicalWorks claim scrubber actually check before a claim is submitted? These are common questions for medical billing teams managing claims in eClinicalWorks.
eClinicalWorks claim scrubbing reviews claims for potential billing, coding, patient, insurance, provider, and submission errors before they move through the claim workflow. Catching these issues early can help reduce preventable rejections and the time spent correcting and resubmitting claims.
But claim scrubbing is only one part of the process. A claim can pass a scrub and still be rejected or denied later because of payer-specific rules, coverage requirements, authorization, medical necessity, or documentation.
This guide explains the eClinicalWorks claim scrubbing process, what the eClinicalWorks claim scrubber can check, why claims may still fail after scrubbing, and the best practices billing teams can use to improve clean-claim performance.
What Is eClinicalWorks Claim Scrubbing?
eClinicalWorks claim scrubbing is the process of reviewing a claim for potential errors before it moves through electronic claim submission. Depending on the practice’s configuration, clearinghouse, payer, and claim type, these checks may involve:
- Patient and insurance information
- Provider information
- NPI and tax ID data
- CPT and HCPCS codes
- Diagnosis information
- Modifiers
- Required claim fields
- Payer-specific requirements
- Provider or specialty rules
The goal is straightforward: Find preventable claim problems before they become submission problems.
eClinicalWorks’ clearinghouse integrations specifically include real-time claim scrubbing as part of the broader claims workflow.
Why Is Claim Scrubbing Important?
A claim error found before submission is usually easier to address than an error discovered after the claim has been rejected or denied. For example, a billing team may identify:
- An incorrect member ID
- Missing claim information
- An incorrect provider
- A coding issue
- A payer-specific requirement
- A problem with claim formatting
Correcting these issues before submission can reduce unnecessary back-and-forth between the practice, clearinghouse, and payer.
CMS describes multiple stages of electronic claim editing. Initial edits check basic claim requirements, while later edits can evaluate claims against applicable coverage and payment policies. Claims that fail different stages can require correction or result in denial.
How Does the eClinicalWorks Claim Scrubbing Process Work?
The eClinicalWorks claim scrubbing process can be viewed as a series of checks that take place before or around claim submission.
1. Patient Information Is Reviewed
The claim starts with accurate patient information. Potential problems include:
- Incorrect patient demographics
- Incorrect member ID
- Incorrect subscriber information
- Wrong relationship to subscriber
- Missing information
eClinicalWorks’ integrated clearinghouse services include insurance eligibility verification alongside real-time claim scrubbing and claim-status tools.
2. Insurance Information Is Checked
The billing team should confirm that the correct payer and coverage information are attached to the encounter. Common issues include:
- Wrong insurance plan
- Incorrect payer selection
- Inactive coverage
- Incorrect member number
- Incorrect subscriber details
Eligibility verification and claim scrubbing address different parts of the workflow. Eligibility confirms coverage information, while claim scrubbing checks the claim for applicable submission problems.
3. Provider Information Is Validated
Claims also depend on accurate provider and billing information. Relevant data can include:
- Billing provider
- Rendering provider
- NPI
- Tax ID
- Specialty
- Billing location
- Provider configuration
eClinicalWorks has published an example involving Compass Health Systems in which its claim-scrubbing configuration used 475 rules to validate information such as tax IDs, provider overrides, and CPT codes across different insurance companies, states, and specialties.
4. Procedure and Diagnosis Information Is Reviewed
Claims contain procedure and diagnosis information that must be reported correctly. Depending on the applicable rules, claim checks may identify issues involving:
- CPT codes
- HCPCS codes
- Diagnosis codes
- Invalid or incomplete information
- Code combinations
- Required claim information
CMS explains that NCCI edits address correct coding and inappropriate code combinations, while NCCI itself is not a medical-necessity or prior-authorization program.
5. Modifiers Are Reviewed
Modifiers provide additional information about how a service was performed or reported.
Potential issues include:
- Missing modifiers
- Invalid modifier combinations
- Incorrect modifier use
- Payer-specific modifier requirements
Modifiers should therefore be based on the actual service, documentation, coding guidelines, and applicable payer rules, not added simply to bypass an edit.
6. Payer-Specific Rules Are Applied
Not every payer processes claims in exactly the same way. A practice may need rules involving:
- Payer
- Provider
- Specialty
- CPT codes
- Tax ID
- Location
- Authorization
- Other payer-specific requirements
The eClinicalWorks Compass Health Systems example shows how claim-scrubbing rules can be configured around insurance companies, CPT codes, tax IDs, provider overrides, states, and specialties.
7. The Claim Moves Through the Clearinghouse
After the applicable checks are completed, the claim can move through the clearinghouse workflow. eClinicalWorks states that its partnered clearinghouse integrations provide:
- Real-time claim scrubbing
- Insurance eligibility verification
- Claim-status updates
- Clearinghouse reports
- Electronic remittance advice
- Patient statements
These services are accessible within eClinicalWorks Practice Management.
What Does an eClinicalWorks Claim Scrubber Check?
The exact edits depend on the practice configuration, clearinghouse, payer, and claim type.
| Claim Area | Potential Checks |
| Patient information | Demographics, member ID, subscriber information |
| Insurance | Payer selection and eligibility |
| Provider | NPI, tax ID, rendering provider |
| Procedures | CPT and HCPCS information |
| Diagnoses | Required or valid diagnosis information |
| Modifiers | Modifier combinations and payer requirements |
| Claim data | Required fields and submission information |
| Payer rules | Payer-specific requirements |
| Provider rules | Specialty, location, and provider configuration |
| Authorization | Required authorization information, where applicable |
Important: These are categories of claim checks, not a claim that every eClinicalWorks or clearinghouse configuration performs every check listed above.
eClinicalWorks Claim Scrubbing vs. Payer Adjudication
This is one of the most important distinctions in the billing process.
| Claim Scrubbing | Payer Adjudication |
| Occurs before or around claim submission | Occurs after the payer receives the claim |
| Looks for potential submission problems | Determines how the payer processes the claim |
| Can identify certain data and coding issues | Applies coverage and payment policies |
| Helps reduce preventable rejections | Can result in payment, rejection, or denial |
| Uses configured edits and rules | Uses payer-specific adjudication rules |
CMS describes this multi-stage process for electronic Medicare claims. Initial edits check basic requirements, followed by additional claim-standard and coverage/payment edits.
So, a clean scrub does not mean a guaranteed payment.
Claim Rejection vs. Claim Denial
Understanding this difference makes claim-scrubbing results easier to interpret.
Claim Rejection
A rejection generally means the claim did not pass a required processing or submission edit. The claim may need to be corrected and resubmitted.
Claim Denial
A denial occurs when the payer processes the claim but determines that payment should not be made as billed. The next step may involve:
- Claim correction
- Appeal
- Medical record review
- Authorization review
- Coding review
- Payer follow-up
The exact action depends on the reason for the denial. CMS similarly distinguishes claim edits that require correction from later edits that can result in denial.
Common Problems eClinicalWorks Claim Scrubbing Can Help Identify
- Incorrect Patient or Insurance Information: Incorrect member IDs, subscriber details, or payer information can interfere with claim processing.
- Provider Data Errors: Incorrect NPI, tax ID, rendering provider, or billing information can trigger claim issues.
- Coding Problems: Invalid or incomplete procedure information can result in claim edits. CMS’s NCCI program, for example, uses procedure-to-procedure and medically unlikely edits to identify certain coding and unit-of-service problems.
- Modifier Issues: A modifier may be missing, incorrectly reported, or inconsistent with the procedure combination.
- Missing Claim Information: Required information that is incomplete or invalid can cause a claim to fail an electronic edit.
- Payer-Specific Requirements: A claim that works for one payer may require different information or handling for another.
5 Common Reasons for Claim Rejection After Scrubbing
Claim scrubbing reduces preventable errors, but it cannot eliminate every claim problem.
1: The Payer May Apply Additional Edits
A payer can apply processing rules after receiving the claim. CMS explains that claims undergo different levels of edits, including later edits related to coverage and payment policies.
2: The Data May Be Complete but Incorrect
For example, a member ID may be entered in the correct field but still be wrong. A completed field does not necessarily mean the underlying information is accurate.
3: Coverage Can Change
A patient’s insurance may change between visits or even during an episode of care.
4: Authorization May Be Required
A claim can contain valid technical information but still require an authorization that was not obtained.
5: Documentation May Not Support the Claim
A claim may pass technical edits while the payer later determines that the documentation or medical record does not support payment.
How to Improve eClinicalWorks Claim Scrubbing
Effective claim scrubbing is not just about fixing errors when they appear. Billing teams should use rejection patterns, accurate data, and workflow reviews to catch recurring problems before claims are submitted.
Keep Patient and Insurance Information Current
Accurate registration is the first step toward a clean claim. Before submission, confirm:
- Patient name, date of birth, and demographics
- Member ID and group number
- Subscriber name and relationship
- Correct insurance payer and plan
- Eligibility status
- Coverage dates
Incorrect or outdated insurance information can cause claims to fail even when the procedure and diagnosis are coded correctly.
Keep Provider Information Accurate
Provider data should match the information required for claim submission and payer processing. Regularly review:
- Billing provider
- Rendering provider
- NPI
- Tax ID
- Specialty
- Practice location
- Payer enrollment information
Provider changes, new locations, or enrollment updates should trigger a review of the related claim setup.
Analyze Recurring Claim Rejections
Fixing the same rejection repeatedly does not address the underlying problem. Track rejection patterns by:
- Payer
- Provider
- CPT or HCPCS code
- Modifier
- Rejection reason
- Practice location
For example, if the same payer rejects claims from the same provider for the same issue, the problem may be related to workflow, provider setup, or claim configuration.
Use rejection data to identify problems that can be corrected before the next claim is submitted.
Configure Workflows for High-Volume Errors
When the same preventable error occurs frequently, review whether the workflow or claim-scrubbing rules can catch it earlier.
The Compass Health Systems example shows how claim-scrubbing rules in eClinicalWorks can be configured around requirements involving payers, providers, tax IDs, CPT codes, and specialties.
The goal is not to add unnecessary edits. It is to identify rules that address real, recurring claim problems without creating avoidable work for the billing team.
Monitor Claims Beyond the Scrubbing Stage
Claim scrubbing is only one checkpoint in the revenue cycle. Continue monitoring claims after they leave the scrubbing workflow. A useful claim-tracking sequence is:
- Claim created
- Claim scrubbed
- Claim rejected
- Claim accepted
- Claim processed
- Claim denied
- Claim paid
This helps the billing team identify where a claim problem occurs and whether the issue starts with claim data, clearinghouse edits, payer processing, or post-adjudication activity.
eClinicalWorks Claim Scrubbing Checklist
Before submitting a claim, verify:
- Patient demographics are accurate
- Insurance information is current
- Member and subscriber information is correct
- Correct payer is selected
- Billing provider is correct
- Rendering provider is correct
- NPI and tax ID are accurate
- CPT/HCPCS information is correct
- Diagnosis information is complete
- Modifiers are supported
- Authorization requirements are addressed
- Required claim information is complete
- Payer-specific requirements are reviewed
- Scrubbing errors are resolved
- Claim status is monitored after submission
Conclusion
eClinicalWorks claim scrubbing provides an important checkpoint in the medical billing workflow. It helps identify potential problems before claims move through clearinghouse and payer processing. The process can involve patient information, insurance data, provider details, coding, modifiers, claim fields, and payer-specific requirements, depending on the applicable configuration. eClinicalWorks also integrates real-time claim scrubbing through its partnered clearinghouses.
For stronger clean-claim performance, billing teams should combine accurate front-end data with appropriate coding, payer-specific rules, rejection analysis, and ongoing claim monitoring.
The best approach is not simply to scrub more claims. It is to identify recurring problems early, correct their root causes, and continuously improve the billing workflow.
Frequently Asked Questions
What is eClinicalWorks claim scrubbing?
eClinicalWorks claim scrubbing is the process of checking claims for potential errors before or around electronic submission. eClinicalWorks’ partnered clearinghouses provide real-time claim scrubbing within its Practice Management workflow.
What is an eClinicalWorks claim scrubber?
An eClinicalWorks claim scrubber refers to the claim-editing and validation process used to identify potential problems before submission. The exact rules available depend on the practice, clearinghouse, payer, and claim configuration.
What does eClinicalWorks claim scrubbing check?
It can involve areas such as patient information, insurance data, provider information, procedure codes, diagnosis information, modifiers, claim fields, and payer-specific requirements, depending on the applicable configuration.
Does eClinicalWorks claim scrubbing prevent all denials?
No. Claim scrubbing can reduce preventable submission problems, but it cannot guarantee payment. Payers can still deny claims based on coverage, medical necessity, authorization, documentation, or other adjudication requirements.
Why can a claim be rejected after it passes the scrub?
A claim may pass one set of edits and encounter additional edits later in the clearinghouse or payer workflow. CMS describes multiple levels of electronic claim edits, including later coverage and payment edits.
How can practices reduce claim rejections in eClinicalWorks?
Focus on accurate registration, eligibility verification, provider data, coding, payer-specific rules, recurring rejection analysis, and post-submission monitoring.
