The Life Cycle of a Medicare Claim

Billing a Medicare claim is one of the more complex tasks providers must frequently perform. Just what happens to a claim once it’s billed? This handy eSolutions infographic illustrates the life cycle of a Medicare claim, from the time of a billable patient visit, through final reimbursement and the important stops in between.

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Each and every claim starts with a healthcare provider. Without a provider, there aren’t any claims to bill. Many different provider types send claims to Medicare including hospitals, home health, hospice, skilled nursing facilities, ambulatory surgery centers, federally qualified health centers, independent physicians, and more.

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Resource Center
We have an ever-expanding library of videos, webinars, and eBooks containing useful information and tips to make healthcare facilities run more efficiently and save money.

Our subject matter experts frequently update our blog and Home Health Resource Center with newsworthy info and proven solutions to the most pressing revenue cycle issues providers face.


Providers use a variety of Practice Management Software programs to streamline their operations. While the functionality of the software may differ depending on the facility type, most Practice Management Software programs include features like patient information storage, appointment scheduling and staff management.

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The eSolutions Advantage
We want to enhance your workflow, not change it, which is why our products can integrate with your existing software regardless of your facility type.

We also offer customized product packages tailored to your specific needs, taking into consideration how your business operates. This means you get the most out of every dollar without extra add-ons you may never need. Our goal is to make complex easy.



Providers must generate an Electronic Claim File (also known as an EDI 837 File) to submit any claim. This file includes Medicare required claim data, and the file can include multiple claims. The 837 holds claim details such as patient description, why treatment was provided, the treatment, and the cost.

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Medicare Connect

Our unique connection allows speedy access and direct claim file submission to the Medicare system via a convenient web-based interface .  You can quickly review which claims have been accepted, rejected, and processed, allowing you to easily prioritize and troubleshoot your workload.


Stop submitting your claims manually and let our Clearinghouse solution, ClaimRemedi, take over. In addition to automating the submission process, our Clearinghouse provides claims scrubbing, tracking and management capabilities.


Providers send Medicare Part A claims to the Fiscal Intermediary Standard System (FISS) for processing. After logging into the FISS, providers can manually perform various tasks such as verifying patient eligibility, checking the status of claims, and correcting them if necessary. 

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Medicare Eligibility Verification

Performing most tasks in the FISS is slow and tedious, but our Medicare Eligibility Verification solution takes that pain away by checking patients’ Medicare eligibility in real time and flagging any data discrepancies such as misspelled names,  incorrect HIC numbers and date of birth.

Medicare Claims Correction

It can take up to two days for claims manually corrected in the FISS to actually update, adding unnecessary days to reimbursement. Our Claims Correction uses a browser-based interface to update claims directly in the FISS with no waiting.



When a claim is being worked by Medicare it is in “suspense”, which means in most cases, the provider won’t need to take any action. However, if Medicare finds something wrong with a claim, it can return it to the provider (RTP), reject it, deny it, or request additional development.

When a provider submits a claim that includes incorrect information, Medicare issues a RTP claim indicating  the provider needs to make fixes. Oftentimes, there are errors in patient name, gender and date of birth the provider must correct for a successful claim.

A rejected claim means that the claim is not payable in its current state and must be corrected and re-submitted. This generally happens when a provider tries to bill the wrong payer or other eligibility issues arise.

Denied claims are the worst case scenario because Medicare won’t pay them and a rebill isn’t allowed. The most common cause for denials occur when Medicare asks for a Request for Additional Development (ADR) to help determine medical necessity, and the provider fails to respond. The only way to rectify a denied claim is to appeal.

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Medicare Enterprise Package

eSolutions’ Medicare Enterprise Package is the most efficient Medicare claims management and analytics system on the market. Eligibility Verification prevents rejections by checking eligibility in real time or through a batch process. Claims Correction easily fixes RTP claims by editing the incorrect information directly in the FISS. Reporting & Analytics lets providers easily track claims and sends alerts when there’s a needed correction.

Multi-Payer Audits & Denials

Keep your claims out of the rejected and denied status and automate the appeals process with Multi-Payer Audits and Denials. This solution allows providers to automate the ADR process and prevent denied claim write-offs. It also enhances the appeals process with integrated notes, workflow support/follow-up and unlimited users.


After a claim has made its way through the Medicare system, an explanation of the results are sent back to the provider in the form of an Electronic Remittance Advice (ERA). This document provides details on payments and reasons for any denials.

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This solution helps providers get a closer look at their claims data. TITAN uses the ERA as a data source and provides reports tracking key revenue cycle indicators. This allows providers to analyze trending denial codes and adjust workflow.