Salient Aspects in Medical Insurance Claims

Due to the cost of medical expenses, most people make practical investments by entering into an arrangement with a health insurance company in order to reduce the impact of medical expenses, such that they are required to pay premiums, which are known as subscription fees, which are scheduled to be paid 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 finishing the paperwork, the patient now sees a designated physician who will provide the consultation and treatment service, as well as other medical procedures that are needed to treat the patient, after which all these services are going to be recorded by the coder and determine the charge cost of each service by the medical biller, such that the summary of these charges is called the medical bill or also referred to as the medical insurance claim.
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Once the coded bill summary is handed to the medical biller, he/she enters all information into an appropriate claim form using a software billing application, which will further be sent to the payer, which is the health insurance company of the patient, and to a clearinghouse, a third-party company, which operates by validating medical claims to check on errors in the document claim.
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If no clearinghouse is hired to validate the claims, when the health insurance company receives the medical insurance claim, there are three possible actions that may occur: 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. Therefore, this indicates the importance of a clearinghouse of which the original bill can be reformatted to include corrections which were validated by the clearinghouse firm and once the new medical claim is presented to the health insurance company, there is a good chance that options, such as denying the claim due to an error and rejection of the claim on account that the services are not covered by the health plan, may be eliminated.