Lesson 0001
Learn the core transaction map for EMR and healthcare SaaS claim workflows.
Insurance Claims and Clearinghouses
EMR claim workflows, one lesson at a time.
Start with the first short lesson: follow a professional claim through eligibility, submission, status, adjudication, and remittance.
Lesson 0002
Map EMR encounter data into the five buckets needed for an 837P professional claim.
Lesson 0003
Separate billing provider, rendering provider, and service facility in provider setup.
Lesson 0004
Learn why provider taxonomy is different from NPI and payer enrollment.
Lesson 0005
Separate patient, subscriber, relationship, and coverage before claim submission.
Lesson 0006
Use 270/271 eligibility checks without mistaking them for payment guarantees.
Lesson 0007
Model patient, subscriber, coverage, eligibility, authorization, and claim snapshot invariants.
Lesson 0008
Version coverage changes without rewriting old visits, eligibility checks, or submitted claims.
Lesson 0009
Separate eligibility observations, authorization requirements, authorization decisions, and claim outcomes.
Lesson 0010
Distinguish batch rejection, claim rejection, denial, remittance adjustment, and claim status signals.
Lesson 0011
Choose whether to resend, replace, void, appeal, or only track claim status.
Lesson 0012
Separate app claim IDs, patient control numbers, clearinghouse IDs, payer claim numbers, and service-line IDs.
References
Use the quick reference sheets for transaction flow, 837P data readiness, provider roles, provider identity, patient/subscriber matching, eligibility triage, insurance data invariants, temporal insurance modeling, eligibility/authorization boundaries, claim outcome triage, claim follow-up actions, and claim identifiers.
Sources: Review the authoritative CMS, NUCC, CAQH CORE, X12, WEDI, and HFMA source list in RESOURCES.md.