The Medical Claims Process: A Simplified Guide

The medical insurance claims process can be quite complex, especially if you don’t work in the field. However, it’s important to understand the steps a claim goes through to know what to expect and how to manage issues that may arise.

What is a Medical Claim?

A medical claim is a request for payment that your healthcare provider sends to your health insurance company.  that lists services rendered. It ensures the doctor gets paid, your insurance pays covered benefits, and you get billed for the remainder. A claim is started the second a patient checks in to an appointment. It follows the entire journey of a health service until the patient receives and pays a final bill.

In the event the patient sees a doctor outside of their network, claims can be filed by the patient themselves. But in general, claims are automatically submitted to insurance via the healthcare provider after an appointment or other service. Rest assured that claims processing centers follow stringent HIPAA guidelines to ensure the safety and security of such sensitive data.

How to File a Claim.

Healthcare providers will, more often than not, send the claims to be processed themselves. After a service, the doctor’s office will gather your claim, along with all relevant information from any insurance forms you filled out plus the medical codes, and send it to a claims processing department or third-party administrator. Your claim form will go through the insurance claims process, and you will receive a bill of any remaining costs after insurance coverage and the doctors are paid.

If you go to a doctor outside of your network, you will likely need to file a claim yourself. The steps, in that case, go like this:

1. Use the correct claim form that aligns with your benefit plan. You can find that by logging into your insurance website with your credentials.
2. If you do it by hand, ensure your handwriting is readable and filled appropriately. But, you can fill this out online.
3. Include all necessary information like date of service and medical codes that you can get from your physician’s office.
4. Check the time limit for submitting your claim after services, and submit it before that date.
5. Verify that the treatment you received is indeed covered by your plan. Your claim will come back as denied if that’s not the case.
6. If needed, include a signed pre-approval form with your claim submission.

What are the Steps of Claims Processing?

Healthcare claims processing goes through a series of steps to ensure accuracy and approval. A claim’s journey actually begins even before you make an appointment. Because insurance may not always cover all services or procedures, it’s important to look over your health insurance to know what is covered and where to go to get in-network care. Once you know what is covered and find a doctor, you call and make the appointment. After you receive your care, the claim begins being processed almost immediately. After an appointment, here are the steps a claim will go through until you receive a final bill.

1. Insurance gets sent a bill for charges of service, not including any charges paid via co-pay upon check-in.
2. A certified claims processor will review the claim ensuring accuracy and comparing against the insurance plan to validate that services rendered were or were not covered by insurance.
3. If services received were covered by benefits, the insurance company will pay the claim based on coverages. They may pay the entire claim in full depending on your plan, otherwise, the remaining balance will be billed to you, the patient.
4. Amounts will be validated and applied to deductible and out-of-pocket totals as they apply to your insurance plan. Those will be updated immediately.
5. An explanation of benefits is sent which lays out a detailed list of services received, how much was covered by insurance, how much the provider paid, and what remains to be billed.
6. A final bill will be sent to you for payment.
7. Before paying the claim, compare the EOB and final bill and ensure everything is accurate and billed correctly. Sometimes balances don’t match up and that could be due to a mismatched procedure code or other clerical error. Claims can be updated and fixed without penalty to you.

What Happens if a Claim is Denied?

An insurance claim can be denied for several reasons, but just because it was denied does not mean that it can’t be remedied. If you receive a notification that a claim was denied, call the appropriate billing provider to discuss the reasons behind the denial. Here are some common reasons for claims denial.

• The wrong claims forms were sent or filled out incorrectly
• The patient received treatments without pre-authorization
• The claim was filed too late
• Insurance isn’t covering the service
• Services received were deemed medically unnecessary

If any of the above is the reason a claim was denied, attempt to resolve it with a phone call. If it cannot be resolved, a claim can go through a formal review with the insurance provider. They can look over the claim at a more detailed level. From there, they will overturn the denial or decide that the claim can be re-submitted with the appropriate information to attempt to get it approved.

What Does SDS Offer for Claims Processing?

Smart Data Solutions offers medical claims management services that include;

• Claims routing specific to your needs. We can configure routes based on member, provider, location, etc.
• Pre-adjudication clinical editing and bill review.
• E01 data exchange and CMS integration for clients offering Medicare supplemental plans.
• Expert data capture for claims, EOBs, bills, etc.

Hiring a facility like Smart Data Solutions to handle your internal claims processing can bring enhanced security, fewer claims denials, and faster turnaround time on the billing process. Many healthcare facilities utilize our services to streamline their workflows from beginning to end. For more information, call us at (651) 894-6400 today!

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