Build & submit a claim

Outcome

Validated charges grouped onto a clean claim, the claim built into the right 837 (P or I), submitted to the right trading partner, and tracked through 999 / 277CA acknowledgment to ACCEPTED.

Prerequisites

Scope	What it lets you do
billing.charge.read	View the charges worklist
billing.claim.read	View list / detail
billing.claim.write	Build, submit, reverse

Charges in VALIDATED, plus a member with active coverage on the DOS (see 2.4) and any required auth attached (2.5).

The claim lifecycle

The full state diagram lives at 9.2 — Status reference.

Steps

1. Open Charges → Ready to bill at /charges?status=VALIDATED. Default filters narrow to charges on members with active coverage. Group as suits the work (see 2.2).

2. Pick the charges you want on a single claim. The platform refuses to mix:

   Boundary	Why
   Different members	One claim = one member.
   Different payers	One claim = one primary payer.
   Different filing types	Professional and institutional submit on different forms.

   If you select a mix, Build claim greys out with a tooltip naming the conflict.

3. Click Build claim. The platform creates a CREATED claim, attaches the charges, and runs the scrubber:

   Scrubber stage	Job
   Modifier injection	Auto-adds modifiers per modifier_injection_rule (e.g. HQ for groups, 95 for telehealth).
   Validation rules	Pre-submit modifier_validation, auth_required, bundle_check, etc.
   Bundling	CCI / MUE compaction.
   Pricing	Applies the contracted fee schedule + any group / per-diem / institutional band.

   If validation fails, the claim stays CREATED with issues attached; fix the underlying charges or auth and click Re-validate.

4. Review the claim at /claims/:id. Tabs:

   Tab	What you see
   Header	Member, payer, dates, totals.
   Charges	The lines on this claim with prices and modifiers.
   Validation	Any pre-submit issues (none on a clean claim).
   Submission	Submission history with EDI trace.
   Relationships	Parent / child claims (rebill, COB chain).
   Institutional	DRG, LOA, occurrence, value codes (837I only).

5. Click Submit. The platform:

   • Promotes the claim to BUILT and writes an edi_transaction row.
   • Routes to the correct trading partner per the routing rules.
   • Renders the 837 (P or I) and queues the file for transport.
   • Promotes to SUBMITTED once the transport confirms delivery.

6. Watch acknowledgments arrive. The Submission tab populates:

   Document	When	Effect
   999	Functional ack — minutes	File parsed cleanly.
   277CA	Claim-level ack — hours	Payer accepted (or rejected) the claim.
   835	Eventual remittance	See 4.1 — ERA inbox.

   A clean run flips the claim to ACCEPTED once the 277CA arrives.

Institutional claims

For per-diem stay billing (residential, ICF, IOP, PHP), the platform builds 837I instead of 837P based on the program's institutionalBillingPeriod setting. The Institutional tab carries DRG, length-of-stay, occurrence codes — see 3.6 — Institutional vs professional and 3.7 — Group billing & per-diem.

Validation

Check	Expected
Build claim produces a CREATED claim	Yes.
Validation passes (clean charges)	Yes; otherwise the issues panel lists fixes.
Submit advances to SUBMITTED	Yes.
999 + 277CA arrive within the partner's SLA	Yes — minutes for clearinghouses, hours for direct payers.
Claim flips to ACCEPTED	Yes, on a clean 277CA.

Troubleshooting

Symptom	Cause	Fix
Build claim greyed out	Selection mixes members / payers / filing types	Narrow the selection.
Validation fails on auth_required	No active auth covers the service	Cancel the build; create or attach an auth (2.5); re-build.
Submission stays in BUILT, never advances	Trading partner credentials expired or routing rule misconfigured	Tenant Manual → Trading partners → Test connection.
277CA rejects with A7 (acknowledged but invalid)	Companion guide violation	Open the 277CA in the Submission tab; the STC element carries the reason; usually a missing field or malformed loop.
Claim flips back from SUBMITTED to BUILT	TA1 envelope rejection (file-level)	Look at the edi_transaction row's error_details; common causes are wrong ISA08 or malformed envelope; rotate credentials and resubmit.

Where to next

• 3.2 — Track acks — what each ack actually means.
• 3.3 — Rebill & correct — when the payer rejects.