Claims go out in a batch, and every one of them changes to “sent.” By Monday they say “accepted.” Six weeks later, nothing has arrived from one insurance company, and its claims still say accepted. Both things are true at once: the claims were accepted, and the insurance company has no record of them. How that can happen is the whole job of understanding what a clearinghouse is: the middleman service that carries your claims to the insurance companies and brings their answers back.
When a clearinghouse fails outright, every practice behind it stops at once, which is what happened in the 2024 industry outage.
Here’s the path, in plain words. A claim is the bill your practice sends to an insurance company for a visit. It doesn’t go straight there, but through the clearinghouse, which checks the claim, carries it to the right insurance company’s electronic mailbox, and brings the answers back. Then the insurance company decides what it will pay, and its explanation of that payment comes back through the same middleman. This article is about the middle of that path, the part between clicking send and the insurance company’s answer, and the three places on it where “accepted” gets said.
What does the AdvancedMD clearinghouse do?
It’s the part of AdvancedMD billing software that carries claims from your system to each insurance company’s electronic mailbox and carries the answers back. On the way out, it checks each claim against edit rules, the automatic tests a claim has to pass before it is sent. On the way back, it receives acknowledgments (the receipts that say a claim arrived). For insurance companies you have enrolled with, it also brings back the electronic payment report (ERA), the insurer’s explanation of what it paid and why. AdvancedMD can record that report against each visit automatically. AdvancedMD states the clearinghouse connects to 1,800 insurance carriers.
The three stops a claim makes
Stop one is the scrubber, the automatic check inside your billing system: before the claim leaves, it’s tested against the insurance company’s rules and against coding edits. A claim that fails here comes back to you the same day with a reason, and nothing has gone anywhere yet.
Stop two is the clearinghouse itself, which takes the claim, checks that it’s formatted the way that insurance company requires, and hands it to the insurer’s electronic front door. “Accepted” at this stop means the clearinghouse took the file and passed it along.
Stop three is the insurance company. Its system acknowledges the claim, then adjudicates it, which means it decides what it will pay: it pays, it denies, or it asks for more. “Accepted” here means the insurance company has the claim and will answer it. Three stops, and the word accepted appears at all three with three different meanings.
Why accepted is different from answered
The claims that sat for six weeks were accepted at stop two: the clearinghouse took them and sent them on. Stop three never happened. The insurance company’s system never acknowledged them, so it never began deciding on them, and nothing came back, because nothing arrived to answer.
That happens for ordinary reasons, and none of them is a fault in the software. The payer ID on file, the code the clearinghouse uses to route a claim to a particular insurance company, points to a mailbox that insurer stopped using. The insurance company takes claims through a different channel, its own website or paper, so the electronic route was never the right one for it. Or the enrollment for that insurer, the paperwork that lets your claims move to it electronically, was started and never confirmed. Each of those looks the same from your screen: sent, accepted, quiet.
Two enrollments per insurance company, and they are separate
Each insurance company needs an enrollment before it will accept your claims electronically. The electronic payment report needs a second enrollment with the same insurer, and the two are separate pieces of paperwork. AdvancedMD’s own page describes helping practices set up those agreements through the clearinghouse, and once the payment-report enrollment is active, the insurer’s payments arrive as a file that AdvancedMD records against your visits. AdvancedMD lists the payment types it records automatically: electronic bank transfers, third-party processor payments, paper checks, and non-payments.
The two enrollments fail independently. An insurance company can accept your claims electronically and still send its payment explanations on paper, which means every one of its payments has to be keyed in by hand. An insurer can have an active payment-report enrollment and stop accepting claims because its payer ID changed. Confirming one tells you nothing about the other.
Status is a setting. Traffic is a fact.
An enrollment screen shows what was requested and what was approved. Whether anything has moved through that connection since is a separate question. At practices we have worked with, a payment-report enrollment can show “approved” for years and never carry a single payment report. Nothing was wrong with the approval, but the traffic had never started, and counting traffic is a different view from confirming a status.
The check that catches it takes three numbers for each insurance company each month: claims sent, acknowledgments received, and payment reports received. Claims going out with no acknowledgments coming back is a routing or claims-enrollment question. Acknowledgments and payments arriving but no payment reports is a payment-report enrollment question. Claims out and nothing at all back for longer than that insurer usually takes is the one to call today, with the claim numbers in hand.
What AdvancedMD already gives you for this
The clearinghouse returns an acknowledgment for every claim it forwards, and the insurance company returns its own acknowledgment when it takes the claim in to decide on it. AdvancedMD’s page lists integrated tracking of each claim’s progress and worklists for rejected claims, so the signals exist for every claim.
What differs between practices is whether anyone reads those signals by insurance company rather than one claim at a time. Claim by claim, a quiet insurer looks like one slow claim after another. Insurer by insurer, it looks like what it is: a connection with money going in and nothing coming out.
What this means for you
Run one list this week: every insurance company with claims sent in the last 90 days, next to acknowledgments received and payment reports received in the same window. Three patterns fall out of it. Claims sent and no acknowledgments: check the payer ID and the claims enrollment. Acknowledgments and payments but no payment reports: file the payment-report enrollment for that insurer. Claims sent and nothing back at all past that insurer’s usual wait: call today with the claim numbers, before the filing deadline (the insurer’s cut-off for accepting a claim) does the deciding for you.
The insurance companies on that list were “accepted” at every stop you can see from your screen. The list is how you see the stop you can’t.
Grab 30 minutes with us. Prep nothing. You will see which of your insurance companies are carrying money and which are only showing a status.
Questions people ask
What does the AdvancedMD clearinghouse do?
It carries claims, the bills your practice sends, from AdvancedMD to each insurance company’s electronic mailbox and brings the answers back. On the way out, it checks each claim against edit rules, the automatic tests a claim must pass. For insurers you’ve enrolled with, it brings back the electronic payment report, which AdvancedMD can record against each visit. AdvancedMD states it connects to 1,800 carriers.
Does AdvancedMD include a clearinghouse?
Yes, AdvancedMD describes the clearinghouse as part of its billing software rather than a separate product. A clearinghouse is the middleman service that carries claims to insurance companies and brings their answers back. Claim checking, claim tracking, and recording payment reports are handled inside the system. Pricing and any per-claim terms are between you and AdvancedMD.
Why does a claim show accepted when the insurance company has no record of it?
Because accepted at the clearinghouse only means it took the file and passed it along. Accepted at the insurance company means the insurer has the claim and will decide on it. A claim can clear the first and never reach the second. The routing code may point to a mailbox the insurer stopped using, or the paperwork to bill that insurer electronically was never confirmed.
How do I enroll an insurance company for electronic claims and payment reports on AdvancedMD?
File two enrollments with each insurance company, one for claims and a separate one for electronic payment reports. Enrollment is the paperwork that lets your claims and payment files move electronically. AdvancedMD’s own page describes helping practices set up those agreements through its clearinghouse. Then confirm each one by looking for traffic, because an approved status alone doesn’t prove anything has moved.
How do I know an insurance company connection is actually working?
Count three things for each insurer each month: claims sent, acknowledgments received, and payment reports received. An acknowledgment is the receipt that says a claim arrived. Claims out with no acknowledgments points to routing or the claims enrollment, and payments with no payment reports points to the payment-report enrollment. Claims out and nothing back past that insurer’s usual wait is a call to make today.
PracticePath is not affiliated with, endorsed by, or sponsored by AdvancedMD. AdvancedMD is a trademark of AdvancedMD, Inc. All references are for descriptive purposes only.