The Art of Mastering Claims

Salient Aspects in Medical Insurance Claims Because the cost of medical expenses is getting more and more expensive each year, people are depending on health insurance to help them pay partially the cost of the medical expenses, which are helpful in their financial and health conditions, and which prompts them to subscribe in health insurance because of the affordable terms, which is paying the premiums in either monthly or annually. When the health insurance subscriber wants to avail of her health insurance for the purpose of seeking medical treatment, she has to hand over her insurance card and fill up a demographic form to enter data requirements, which will be needed later on for processing medical insurance claims, and these are: patient’s name, date of birth, address, Social Security number or driver’s license number, the name of the policyholder, and any additional information about the policyholder, and a government-issued photo ID. After completing the paperwork, she proceeds for consultation and treatment on her health concerns with the healthcare service provider or otherwise referred to as the physician, which after a series of consultations, treatments, and tests, all chargeable costs are going to be documented by a medical biller and coder of the healthcare service provider, to which this document is called the medical bill or the medical insurance claim.
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As soon as the coder hands over the bill of the patient to the medical biller, the information on the bill is entered as information by the medical biller into an appropriate claim form through a software billing application, in which the claim is sent to the health insurance company of the patient and to a clearinghouse, which is a third-party company that operates on checking and validating the document from errors found in the claim.
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When the health insurance company receives the medical claims, if there is no clearinghouse doing the validation, there are three possibilities that the health insurance company can act on the medical claim: accept all expenditures and pay the bill or deny the claim on account of a billing error, to which the bill is returned to the healthcare provider to be corrected or reject the claim on account that the services rendered are not covered within the health plan of the patient. This is where the clearinghouse is of valuable use to help correct errors and check the health plan coverage of the patient, such that when the clearinghouse sends over their validation on the medical claim to the healthcare provider, the medical biller and coder will use the validation as basis to reformat a new medical claim, which will be sent again to the health insurance company and, in this manner, there’s a likely chance that the health insurance company will eliminate its previous options, which are denying the claim due to an error and rejection of the claim on account that the services are not covered by the health plan.