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How Medical Insurance Claims Are Processed 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 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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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.