Choose between real-time claim adjudication and batch 837 submission and implement the appropriate flow for each use case

Steps

1. Assess the use case: real-time adjudication is appropriate for point-of-service copay collection, pharmacy claims (NCPDP Telecom), and high-deductible patient cost estimation; batch 837 submission is appropriate for high-volume professional and institutional claims where same-day adjudication is not required
2. For real-time: use a clearinghouse or direct payer API that returns a synchronous ClaimResponse or proprietary adjudication result within seconds; ensure your integration handles the full response including patient liability amounts before the patient leaves the encounter
3. For batch 837: accumulate claims in your billing system, generate X12 837 files grouped by payer and transaction type, and transmit via SFTP or AS2 to the clearinghouse on a defined schedule (typically daily); monitor for 999 and 277CA acknowledgments within hours of transmission
4. For batch, implement an acknowledgment pipeline: inbound 999 files are matched to outbound ISA control numbers; inbound 277CA files are matched to individual claim ICNs; claims not acknowledged within a defined SLA trigger a re-inquiry or escalation
5. Design your AR aging to account for payer adjudication cycle times: most commercial payers batch-adjudicate claims nightly with 835 remittances available 1–3 business days after receipt; Medicare typically remits weekly; Medicaid cycles vary by state
6. For hybrid workflows (real-time eligibility + batch claims), ensure the eligibility trace number and verified benefit data are stored with the claim record so the 835 posting can reconcile expected vs actual payment