What Claim.MD does

Claim.MD, Inc. is a U.S.-domiciled medical claims clearinghouse headquartered in Pecos, New Mexico, founded in the early 1980s and operated as a privately held, bootstrapped company under founder, President and CEO Rob Stuart. The company operates a web-based EDI clearinghouse platform that processes electronic medical claims, electronic remittance advice (ERA/835), and real-time eligibility transactions using HL7 FHIR and X12 standards (837P, 837I, 5010, 4010), with support for multiple batch file formats including CSV, XLS, XML, NSF, and Print Image. Claim.MD links providers to a nationwide payer network that includes Medicare, Medicaid, Blue Cross, and thousands of commercial insurance companies, with a published payer list spanning 208 pages, and reports processing tens of millions of transactions per month.

The company's commercial offering is organized around three monthly subscription tiers — Unlimited ($120/month), Small Volume ($60/month), and Basic ($30/month pay-as-you-go) — with additional per-transaction fees for overages, paper/fax claims, and electronic attachments. Distribution is multi-channel: self-serve web signup with a 15-minute onboarding flow, inside sales for enterprise prospects, and an embedded OEM/white-label motion through 25+ EHR, EMR, and practice management software integrations (Canvas, Jane, Healthie, ICANotes, Practice Better, EZClaim, Empower EMR, etc.). The company holds an unusually deep compliance stack for its size, including HITRUST CSF r2, SOC 2 Type 2, TX-RAMP Level 2, CAQH CORE, and EHNAC HNAP accreditations.

Customer segments span healthcare providers (hospitals, small practices, billing companies, individual doctors), software vendors integrating clearinghouse connectivity into their platforms, and payers receiving claims electronically. In March 2024, Claim.MD launched a Rapid Onboarding Program explicitly positioned to absorb providers displaced by the Change Healthcare cyberattack, leveraging its 15-minute self-serve signup as a competitive wedge against incumbent clearinghouses.

Name

Claim.MD

Legal name

Claim.MD, Inc.

Website

https://claim.md

Company type

Private

Founded year

1980

Operating status

Operating

Headcount range

11–50 employees

Short description

Claim.MD is a privately held, bootstrapped U.S. medical claims EDI clearinghouse serving SMB healthcare providers, software vendors, and payers with web-based electronic claims submission, real-time eligibility verification, and ERA processing, processing tens of millions of transactions monthly.

Ownership category

akta.pro rank

Product category

Medical Claims Clearinghouse

NAICS

Financial Transactions Processing, Reserve, and Clearinghouse Activities (522320), Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services (518)

SIC

Services-Computer Programming, Data Processing, Etc. (7370)

akta.pro primary industry

Claims Management, Scrubbing & Clearinghouse (HLACACAB)

akta.pro secondary industries

Claims Administration & Payment Integrity (Medical/Dental/Vision) (HLAEALAD), Payer-Provider Data Exchange (X12, prior auth, claims/clinical attachment) (HLACABAK), Clinical Document & Data Exchange (C-CDA, CCD, Direct Messaging) (HLACABAI)

Keywords

• Medical claims clearinghouse
• Electronic data interchange
• Claims processing software
• Eligibility verification
• Healthcare revenue cycle

Headquarters

HQ city

Pecos

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Software

Cost components

Technology or R&D, Personnel, Infrastructure, Operations, Marketing or Sales, Others

Revenue model

1. Claims Processing: Subscription-based medical clearinghouse services with tiered pricing. Providers pay monthly subscriptions to submit electronic claims, with additional charges for overage claims beyond plan limits.
2. ERA/Electronic Remittance: Electronic remittance (ERA/835) included in subscription tiers with additional per-transaction charges for overage.
3. Eligibility Transactions: Eligibility verification services included in tiers with tiered pricing for additional transactions (Prime $0.02/ea, Non-Prime $0.10/ea on Unlimited plan).
4. Paper/Fax Claims and Attachments: Additional fees for paper and faxed claims ($1.00/ea for 5 pages, $0.20/aditional pages) and electronic attachments ($0.60/ea).

Pricing tiers

Go-to-market motion2 records

Distribution channels3 records

Marketing channels6 records

Core offering

Claim.MD is a medical claims clearinghouse that processes electronic professional (837P), institutional (837I), and dental (837D) claims in real time between healthcare providers and payers. The platform provides a unified web portal, HL7 FHIR APIs, and SFTP integrations for claims submission, eligibility verification, electronic remittance advice (ERA/835), and claims correction workflows. It is HITRUST CSF r2 certified, SOC 2 Type 2 audited, EHNAC HNAP accredited, CAQH CORE certified, and TX-RAMP Level 2 certified, processing tens of millions of transactions per month for providers, software vendors, and payers.

Product overview

Claim.MD is a comprehensive medical claims clearinghouse platform providing electronic claims management solutions for healthcare providers, software vendors, and payers. The core product is the Claim.MD Clearinghouse Portal, a web-based platform that handles the complete claims lifecycle including electronic claim submission (837P, 837I), real-time eligibility verification, electronic remittance (ERA/835), and claims correction workflows. The platform offers tiered subscription plans (Unlimited, Small Volume, Basic) and integrates with numerous EHR, EMR, and practice management software vendors. Supporting services include Software Vendor Integration for SFTP/API connectivity and Payer Services for insurance companies. The platform emphasizes claims quality through automated validation, real-time error notifications, and visual tracking to help providers submit clean claims the first time.

Differentiator

Problem solved

Functional benefit

Products and services

• Claim.MD Clearinghouse Portal Subscription-based web portal for healthcare providers, billing companies, and software vendors to submit, validate, track, and manage professional, institutional, and dental claims (837P, 837I, 837D) plus real-time eligibility (270/271) and electronic remittance (ERA/835) transactions with payers.
• Provider Services Clearinghouse service offering tailored to healthcare providers (hospitals, individual doctors, and billing companies) for electronic claims, eligibility, and remittance processing.
• Software Vendor Integration Integration offering for software vendors (EMR/EHR/practice management platforms) that embed Claim.MD's clearinghouse capabilities into their products, supported by HL7 FHIR APIs and SFTP integration.
• Payer Services Clearinghouse service offering for payers and Managed Care Organizations to receive and process inbound electronic claims, eligibility, and remittance transactions at scale, including multi-state Medicaid Managed Care connectivity.
• Vendor Integration Program Formal program for software vendors to integrate with Claim.MD's clearinghouse, enabling embedded claims and eligibility workflows within their own products.
• Rapid Onboarding Program Program launched in March 2024 to accelerate integration of software vendors with the Claim.MD clearinghouse, supporting faster go-live for vendor partners.

Quantifiable outcome

• Self-guided onboarding enables providers to sign up and begin billing in as few as 15 minutes (Medicare enrollments take 3-4 days)
• +1 more outcomes

Named customers6 records

Segments3 records

Ideal customer profiles3 records

Technology focussed Yes

API detail

Has API

Yes

API docs

API detail

Core technology

AI maturity

App detail

Integration24 records

Feature5 records

Partnerships

14 partnerships are on record, tiered core.

• ABA MatrixcoreTechnology or IntegrationABA Matrix is a dynamic platform for ABA agencies featuring data collection, reporting, graphing, compliance alerts, billing, and payroll. Integrated with Claim.MD for streamlined claims submission.
• AcuBlisscoreTechnology or IntegrationPractice management app for acupuncture specialty medical practices founded in 2012. Integrates with Claim.MD for billing and claims processing.
• BestNotescoreTechnology or IntegrationHIPAA compliant CRM and EHR database system designed for behavioral health and substance abuse industry. Integrated for seamless claims processing.
• Blueprint SolutionscoreTechnology or IntegrationCloud-based audiology software for hearing healthcare professionals. Integrates with Claim.MD for practice management and billing.
• Canvas MedicalcoreTechnology or IntegrationHuman-centered EMR platform enabling better clinical decisions and superior patient care. Integrated with Claim.MD for claims processing.
• CounselEARcoreTechnology or IntegrationHearing care clinic management software that integrates office workflow online. Partners with Claim.MD for billing and claims submission.
• Empower EMRcoreTechnology or IntegrationAll-in-one Physical Therapy Software platform and EMR for outpatient practices. Integrated with Claim.MD for billing and claims processing.
• EZClaimcoreTechnology or IntegrationMedical billing and scheduling software since 1997, based in Rochester, MI. Tailored for single to multi-provider practices. Integrates with Claim.MD.
• HealthiecoreTechnology or IntegrationCloud-based platform combining EHR, practice management, and patient engagement tools. Supports behavioral health, nutrition, and chronic care management. Integrates with Claim.MD.
• ICANotescoreTechnology or IntegrationSoftware solution for behavioral health practices with button-driven narrative charting capabilities. Cloud-based, best suited for midsize to large behavioral health clinics. Integrates with Claim.MD.
• JanecoreTechnology or IntegrationAll-in-one EHR and practice management platform offering branded online booking, scheduling, integrated insurance billing, telehealth, and payment processing. Integrates with Claim.MD.
• Practice BettercoreTechnology or IntegrationLeading all-in-one modern EHR and practice management platform for health and wellness practitioners. Used by thousands in 70+ countries. Integrates with Claim.MD.
• Practice ProcoreTechnology or IntegrationTherapy practice management software offering cloud-based EMR and practice management with scheduling, EMR, outcomes, billing and collections. 20+ years of business and clinical expertise. Integrates with Claim.MD.
• TherapyMatecoreTechnology or IntegrationEHR and Practice Management Software for Social Workers, Therapists, Counselors, Psychiatrists and Psychologists with cloud hosted environment. Integrates with Claim.MD clearinghouse billing.

Scale indicators4 records

Recent moves6 records

Expansion highlights5 records

Direct peers

• Office Ally: Long-standing US medical clearinghouse offering web-based claim submission, ERA, and eligibility with similar SMB-friendly pricing model. Directly comparable as a low-cost, provider-focused clearinghouse alternative competing for the same small-practice and billing-company customers.
• Waystar: Public cloud-based healthcare payments platform combining clearinghouse functionality with broader revenue cycle management (denial management, patient estimation, analytics). Compares to Claim.MD as a claims clearinghouse but competes primarily in the mid-market and enterprise tiers where Claim.MD is less represented.
• Availity: One of the largest US healthcare clearinghouses, jointly owned by major Blues plans. Directly comparable to Claim.MD as an EDI clearinghouse connecting providers and payers for claims, eligibility, and remittance, though at significantly larger scale and with deeper Blues-plan ownership.
• Change Healthcare (Optum): Pre-2024 cyberattack, the dominant US medical clearinghouse processing billions of claims annually. Now part of Optum/UnitedHealth Group, it directly competes with Claim.MD across professional and institutional claims submission, eligibility, and ERA. Its 2024 outage is the single most important catalyst for Claim.MD's recent customer acquisition.
• ZirMed (now part of Waystar): Pre-merger cloud-based clearinghouse and patient billing platform merged into Waystar. Historically a direct SMB and mid-market clearinghouse competitor with similar SaaS pricing model and feature set to Claim.MD's portal.

Broad incumbents

• Experian Health: Healthcare arm of Experian offering eligibility verification, claims management, and identity/patient access solutions. Comparable to Claim.MD in clearinghouse functions but bundled into a much larger enterprise RCM portfolio and supported by Experian's data assets.
• Trizetto (Cognizant): Established healthcare clearinghouse and payer-side claims platform now owned by Cognizant. Overlaps with Claim.MD in EDI clearinghouse but operates across a much broader enterprise and payer-facing portfolio including payer claim editing and benefits administration.
• Optum (UnitedHealth Group): Parent of Change Healthcare and a dominant player across payer operations, RCM, and clearinghouse services. Represents the largest competitive threat and strategic acquirer in the space, directly comparable in clearinghouse scope though vastly larger in scale and scope.
• Cerner/Oracle Health: Major EHR vendor (now Oracle) that bundles payer-provider data exchange and clearinghouse-like capabilities into its enterprise platform. Represents both a peer in payer-provider data exchange and a potential channel/competitor for Claim.MD's provider-side business via embedded clearinghouse relationships.

Emerging players

• QuadaPay: Emerging digital claims and payment platform targeting providers and payers with claims processing and ERA capabilities. Comparable in clearinghouse function but smaller and less established, competing with Claim.MD for next-generation integrations and API-first customers.

Market position

Strengths1 record

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Xx.com/claimmd
• Facebookfacebook.com/ClaimMD
• LinkedInlinkedin.com/company/claim.md

Compliance5 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles5 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Claim.MD