3.1
The claim journey
Step through the four checkpoints and see where a claim can stall.
Claim journey simulator
Pick a scenario01
EHR Internal Scrub
Basic validation & locked note checks.
02
Waystar Clearinghouse
Verifies HIPAA 837 loops, segments & payer IDs.
03
Payer Gateway
Checks patient DOB, member ID, provider NPI.
04
Adjudication Engine
Medical necessity, coverage & deductibles.
…
3.2
Rejections vs. denials
Front-end rejection (pre-adjudication)
Caught at Waystar or the payer gateway. Caused by typos, invalid NPI, inverted DOB or missing subscriber ID. The claim was never opened by an adjuster — fix the field in the EHR and re-transmit.
Back-end denial (post-adjudication)
Issued by the payer's adjudication engine for medical necessity, non-covered benefit, deductible or credentialing lapse. The claim was evaluated — appeal with notes, correct modifiers, or write off.
Sort it: rejection or denial?
1 / 6Patient's date of birth entered as 07/03 instead of 03/07
Key takeaways
- Claims pass EHR scrub → Waystar → payer gateway → adjudication.
- Rejections: never reviewed, fix data and resend.
- Denials: reviewed against policy, require appeals or adjustment.
- Paid claims generate an ERA / 835.