All About Clearinghouses

Most claims are routed to payers via clearinghouses. There are hundreds of clearinghouses. Clearinghouses are depots where the electronic claims are dropped off. The clearinghouse checks the dropped off claims, makes sure they are configured correctly and then sends them on to the payer for processing.

Clearinghouses got started before HIPAA, in the days when there was little in the way of standardization and when different payers had different requirements for payment. The first clearinghouses took the paper HCFAs (as well as electronic formatted claims) submitted by the doctor’s office, formatted the claims to meet the specific requirements of the payer, and then sent them to the payer in the digital format the payer accepted. Thus clearinghouses were switchboard operations that could translate incoming claims into the format used by specific payers.

HIPAA was designed to create one standard language for claims. That language is called x12. Some thought that this would eliminate the need to have clearinghouses: out of the Babel of competing languages the universal language of X12. Even though all payers are now required to accept and use X12 exclusively, this has not eliminated clearinghouses. As it happens payers can configure their claims requirements in a limitless number of idiosyncratic ways. Clearinghouses are expert at dealing with this complexity and so they live on.

Clearinghouses are the depots where electronic claims are routed. If the claim sent in has missing data, is not configured correctly, etc most clearinghouses will send back feedback indicating as much. There are some pieces of information clearinghouses do not have, e.g. subscriber ID, eligibility, etc. So even if a claim is passed by the clearinghouse to the payer, it may get rejected at the payer level because the client is no longer covered or the subscriber # is incorrect and so on.

Some clearinghouses are free, e.g. Availity; most you have to pay for. One of the great privileges of being a behavioral health clinician is that in most instances you must pay to get paid. Free clearinghouses like Availity are paid by the payers for routing clean electronic claims to them. Insurers save money when they don’t have to deal with paper claims (you need staff to open them, scan them, correct the illegible input, etc), so paying a clearinghouse a small amount per claim to route claims to them is a net savings.

However, not all payers deal with Availity or other free clearinghouses. The Anthem for profit Blue Cross Plans only connect with clearinghouses that charge, for instance. Most non-profit Blue Cross Plans use Availity.


Let’s take a look at the price for some clearinghouses.

Availity--free for unlimited claims they connect to electronically. (Availity connects electronically to over 1500 payers) They offer to send claims in paper HCFA format onto those who they don’t connect to for $.38 per claim.

ENS--up to 100 claims $49.95/month setup $200

Gateway EDI--unlimited claims $85 /$114/mo per clinician

I-Plexus--$.15 per claim

Clearinghouses offer additional services, e.g. real time eligibility look-up, electronic remittance advice, etc.