How to Map Payer-Facing Work at a Billing Company: Volume, Touches, and Channel

Updated November 5, 2026, based on CMS, the eCFR and CAQH as of that date.

To see where your team's payer time goes, list each payer-facing workflow and count three things for it: how many requests came in, how many times a person touched each request, and which channel finally finished it (EDI, portal, phone or fax). Most of the time goes to requests that fall back to a person.

An eligibility check that goes out as a 270 and comes back as a usable 271 takes almost no staff time. A claim status check that needs a portal search, then a call, then a note in the practice management system takes three touches. If the claim is still pending next week, it takes three more.

Hours-per-person reports can't show you that. They tell you who is busy, and they mix in skill level, payer mix and interruptions. A map of volume, touches and channel tells you which work is keeping them busy, and you can build most of it from data you already have.

List the payer-facing workflows your team owns

Start with the work where your staff deals directly with a payer. HIPAA names standard electronic transactions for most of it. CMS's list of HIPAA standard transactions includes eligibility, claim status, and referrals and authorizations. The HIPAA transaction standards in 45 CFR Part 162 name the X12 format for the first three below:

• Eligibility and benefits: the 270 inquiry and the 271 response.
• Claim status: the 276 request and the 277 response.
• Prior authorization and referrals: the 278 request for review and its response.
• Credentialing and payer enrollment for your clients' providers.

Credentialing has no HIPAA standard transaction. The enrollment transaction in Part 162 covers subscribers enrolling in a health plan, not providers joining a payer's network. That means there's no EDI baseline for this row, and every request goes through whatever channel the payer uses.

Add any other payer-facing work your team handles, such as appeals or claim corrections. Leave out internal work like charge entry. Each row should be a workflow one manager could own.

Count volume and touches per request, not hours per person

For each workflow, count requests over a sample period. A request is one unit of work: one eligibility check for one visit, one status check on one claim, one authorization for one service, or one credentialing application for one provider with one payer.

Then count touches per request. A touch is each time a person acts on the request:

• Logging into a portal and searching.
• Placing or taking a call.
• Sending a fax, or keying in a fax that came back.
• Rechecking a request that wasn't resolved the first time.

A 270 that goes out automatically and returns a 271 your team can use has zero touches. A status check that takes a portal search and then a phone call has two.

The data usually lives in a few places. Clearinghouse reports give EDI volume. Work queues and account notes in the practice management system show who worked what. Phone system logs and fax logs fill in the rest. Where none of these exist, have staff tally their touches for the sample period.

The 2025 CAQH Index Executive Report notes that "some transactions may occur multiple times or in multiple steps and be triggered by other events." Touches per request measures that in your own operation. Multiply volume by touches per request, and you get a workload number you can compare across workflows.

Record the channel that actually finished each request

For each request, record the channel that produced the answer, not the one you tried first. If a 276 went out and the 277 didn't answer the question, and someone then checked the portal and finally called, the finishing channel is phone. Use a short, fixed list of buckets (EDI, portal, phone, fax) so the counts add up.

CAQH's national figures give a rough reference point. In the 2025 CAQH Index, medical plans reported fully electronic adoption of 96% for eligibility and benefit verification, 81% for claim status inquiry, and 40% for prior authorization. CAQH sorts transactions into fully electronic, partially electronic and manual, so the rest of each workflow is partly or fully manual. These are plan-reported shares across the industry. Your numbers will depend on your clients' payers and specialties, so treat CAQH's figures as context rather than a target.

Note the dates of your sample, too. CAQH's report describes how, after a major 2024 cyberattack on a clearinghouse, payers and providers relied, in some cases, "more on portals and manual processes while restoring automated connections." A clearinghouse outage or switch during your sample will push requests out of EDI and into portals and phone calls.

Split by payer to see where manual work clusters

Run the same counts by payer. Payers differ in what they support electronically and in how complete their responses are. One payer's 271 may carry the benefit detail your team needs, while another's sends staff to the portal. One payer may take a 278, while another requires its own portal or a faxed form. Confirm each payer's options in its provider manual or with your clearinghouse.

A simple grid works: payers as rows, workflows as columns, and in each cell the volume, touches per request and most common finishing channel. Sort by total touches. The payers at the top of that list are where your manual work sits. If you serve several clients, add a client column as well, since specialty and payer mix change from one client to the next.

Read the map: high volume, many touches and a manual channel

Staffing pressure comes from cells where all three show up at once: high volume, several touches per request, and a finishing channel that needs a person. A high-volume eligibility workflow that finishes by EDI barely registers. A medium-volume claim status workflow that finishes by phone for a few large payers can take up much of an AR team's week.

A low-volume workflow with many touches per item, like credentialing, can feel heavy day to day. Multiply it out before ranking it against the high-volume rows.

For each heavy cell, the fix depends on why the work falls back to a person:

• If EDI is available but not set up, start with your clearinghouse enrollment for that payer and transaction.
• If the payer's electronic response is incomplete, standardize the portal or phone step so it happens once per request, not on every recheck.
• If the payer offers only a portal or phone, the choices are staffing it, batching it, or automating it. The guides to claims follow-up automation, insurance eligibility verification automation and prior authorization automation cover what each workflow involves.

Frequently asked questions

How long should we sample?

Long enough to cover your normal payer and client mix and at least one full cycle of your follow-up cadence. If claim status follow-up runs on a 30-day cycle, a one-week sample will miss most rechecks. Avoid weeks with an outage or a clearinghouse change, or note them.

Do we count rework?

Yes. A recheck on a pending claim, a resubmitted authorization or a corrected credentialing application is another touch on the same request. Track rework separately if you can, because it calls for a different fix than first-pass manual work.

What counts as a touch?

Any time a person acts on the request in a payer channel: a portal search, a call, a fax sent or keyed, or a recheck. Writing up the result counts when it's a separate step from getting it. Count a call as one touch however long the hold was, and log handle time separately if your phone system records it.

How often should we redo the map?

Redo it when something changes the inputs: a new client, a payer changing its portal or EDI support, or a clearinghouse switch. Otherwise a refresh once or twice a year keeps it current enough for staffing decisions.

Seeing a lot of portal and phone work on your map?

Champ automates payer portal work like eligibility checks and authorizations, and can take on payer calls and documents too. We set it up and run it, so your team sees only the finished results. If your map shows a lot of work falling back to portals and phone, learn more here.

This post is general information, not legal, compliance or billing advice. Rules vary by payer and change often, so confirm with each payer or your clearinghouse before acting. Champ is not affiliated with or endorsed by CMS, HHS or CAQH.