What is the Process of Claim Scrubbing?

Clean claims are the backbone of a healthy revenue cycle, yet behavioral health providers face some of the highest denial rates in healthcare. With insurers intensifying scrutiny, even minor claim errors can delay reimbursement, create administrative burden, or result in a complete denial. That’s where claim scrubbing becomes essential. Claim scrubbing is the process of reviewing claims for accuracy, completeness, and compliance before submitting them to payers.

At Hansei Solutions, clean claims are central to how we help behavioral health providers stay financially stable. A strong claim scrubbing process prevents errors before they reach the payer—protecting reimbursement, reducing rework, and improving overall efficiency.

What Is Claim Scrubbing?

Claim scrubbing refers to reviewing a medical claim to ensure all coding, patient information, documentation details, and payer-specific requirements are accurate and compliant. This process occurs before the claim is submitted and acts as a quality checkpoint to prevent rejections and denials.

Claim scrubbing typically evaluates:

• ICD-10 and CPT/HCPCS coding accuracy
• Modifier usage
• Patient demographic accuracy
• Authorization requirements
• Provider credentialing details
• Medical necessity indicators
• Payer-specific rules and formatting
• Claim completeness and structure

According to the American Medical Association, claim errors account for up to 42% of all payer denials, many of which can be fixed with proper scrubbing before submission.

Why Claim Scrubbing Is Critical for Behavioral Health Providers

Behavioral health, unlike many other specialties, faces unique complexities:

• Time-based psychotherapy codes
• Multiple documentation requirements
• High rates of medical necessity reviews
• Frequent prior authorization requirements
• Complex ICD-10 mental health and SUD diagnoses
• Higher likelihood of payer audits

A single missing modifier or incorrect code can lead to unnecessary denials—especially in substance use and mental health treatment, where payers require extensive justification for services.

Claim scrubbing reduces:

• Claim rejections
• Administrative workload
• Cash flow disruptions
• Audit risk
• Underpayments
• Delays in patient accounts

For behavioral health programs, a reliable claim scrubbing system is one of the strongest defenses against reimbursement loss.

The Step-by-Step Process of Claim Scrubbing

While every organization has its own workflow, most claim scrubbing systems follow six key steps:

Step 1: Data Accuracy Check

The first step is verifying that all patient and provider information is correct. This includes:

• Legal name and date of birth
• Insurance policy number and coverage status
• Service dates
• Rendering provider credentials
• Place of service codes
• Taxonomy numbers

Errors in demographics or eligibility are among the top reasons claims are rejected. According to the Medical Group Management Association (MGMA), eligibility and demographic errors make up nearly 20% of rejected claims.

Step 2: Coding Validation

Next, the claim is examined for coding accuracy:

• ICD-10 diagnosis codes
• CPT/HCPCS procedure codes
• Relevant modifiers
• Time-based coding requirements
• Appropriate coding for telehealth services

Behavioral health is particularly vulnerable here. Time-based psychotherapy codes (e.g., 90834 vs. 90837) must be precise, and documentation must support each service.

Step 3: Payer-Specific Rule Review

Every payer has its own coverage criteria, formatting standards, and billing rules. Claim scrubbers—whether software or specialist teams—check for:

• Prior authorization requirements
• Accepted modifiers
• Telehealth rules
• Frequency limitations
• Covered diagnoses
• Bundled services
• Required NPI formatting

Failing to follow a payer’s rules almost always results in a denial.

Step 4: Medical Necessity Confirmation

This step ensures the documentation supports the service billed. Claim scrubbing involves verifying that:

• The diagnosis aligns with the CPT code
• The service is medically necessary
• Risk assessments, treatment plans, and notes are complete
• Appropriate clinical justifications are included

Medical necessity remains one of the most common denial reasons across all payers.

Step 5: Compliance Check

Compliance review ensures the claim meets legal and regulatory standards:

• HIPAA formatting rules
• CMS guidelines
• Documentation integrity
• Audit-proof coding
• Accurate reflection of services

Compliance scrubbing protects organizations from financial and legal risk.

Step 6: Claim Optimization and Final Review

Before submission, scrubbers identify opportunities to reduce denial risk and optimize reimbursement. This includes:

• Clarifying coding or modifiers
• Adding missing information
• Fixing formatting issues
• Ensuring the claim meets all payer requirements

Once a claim passes this final review, it is submitted to the payer as a clean claim, helping ensure quick payment.

Manual vs. Automated Claim Scrubbing

Claim scrubbing can be done by humans or software—and both approaches serve important but different purposes. Manual scrubbing offers clinical insight and careful review, while automated tools quickly flag coding and formatting errors. Understanding how each method works helps providers build a more accurate, efficient, and reliable claims process.

Manual Claim Scrubbing

Performed by trained billing or coding specialists who review each claim by hand.

• Benefits: Higher accuracy, specialized insight, and real-time communication with clinicians.
• Challenges: Time-intensive, requires skilled labor.

Automated Claim Scrubbing

Uses software to identify common coding or formatting issues.

• Benefits: Fast, scalable, reduces repetitive errors.
• Challenges: Cannot interpret clinical nuance or medical necessity documentation.

Most organizations benefit from a hybrid model—automated scrubbing supported by human expertise. At Hansei Solutions, our team uses advanced workflows combined with hands-on specialists to ensure claims are compliant and optimized.

How Claim Scrubbing Improves Revenue Cycle Performance

Accurate scrubbing leads to:

• Higher first-pass acceptance rates
• Faster reimbursement
• Fewer administrative reworks
• Reduced need for appeals
• Better cash flow
• Lower denial rates
• Reduced audit risk

According to the Council for Affordable Quality Healthcare (CAQH), improving claims accuracy could save the healthcare system over $12 billion annually in administrative costs.

FAQs: Claim Scrubbing

What is the primary goal of claim scrubbing?

The goal is to identify errors, omissions, or compliance issues before a claim is submitted—reducing denials and improving reimbursement.

Is claim scrubbing the same as claims editing?

They are similar but not identical. Claims editing focuses on coding and formatting, while scrubbing includes payer rules, medical necessity checks, and documentation validation.

How often do behavioral health claims get denied?

Behavioral health has some of the highest denial rates in healthcare due to strict medical necessity requirements and complex coding. Claim scrubbing helps reduce these avoidable denials.

Who performs claim scrubbing?

A combination of billing specialists, medical coders, utilization review staff, and automated software tools often participate in the scrubbing process.

Does Hansei Solutions provide claim scrubbing services?

Yes. Claim scrubbing is built into our full-service revenue cycle model, helping providers improve accuracy, reduce denials, and strengthen financial performance.

Claim Scrubbing at Hansei Solutions

At Hansei Solutions, claim scrubbing is integrated into our entire revenue cycle process. Our team:

• Reviews claims for accuracy and compliance
• Verifies coding and payer requirements
• Identifies missing documentation
• Reduces avoidable denials
• Supports appeals with strong evidence
• Ensures clean claims submission across all levels of care

With payer audits increasing and utilization guidelines tightening every year, thorough claim scrubbing is essential for financial stability. Connect with Hansei Solutions to strengthen your claim accuracy and reimbursement performance.