When a patient receives medical treatment at the hospital or clinic, that organization starts the procedure of claiming the insurance with the companies. This procedure or interaction is done by the trained professional called the medical biller. Professional billers get the medical biller training for this task.
This process has some steps:
Checking eligibility – Before the treatment, the healthcare provider checks the eligibility of the patient for that treatment. They check it using computer software with the insurance company. If the patient is eligible according to the software, they provide the services.
Generating the codes – When the physician treats the patient, some procedure codes are generated and assigned to them. These codes carry the information of the diseases and treatment received by the patient. These codes are useful for the insurance companies. They calculated the coverage with the help of these codes.
Developing the form – After the codes are generated, the biller collects these codes and develops the claim.
Submitting – After deciding the codes, the claim will be submitted to the company by the biller.
Processing – Claims get processed at the company by their experts and examiners. They review, evaluate, and process them. When it comes to the higher payments, these companies take the help of medical directors.
Failed – Sometimes when the examiners review the claim, they do not find them payable. In that case, the form is returned to the healthcare provider. In this situation, there are two types, one is rejected, and the other is denied. A denied claim is usually reviewed by the expert of insurance companies. If the expert does not find it payable, he denies it. In that case, it can be reconsidered after making some correction. The rejected one is cancelled by the examiner because of some major error in the form or the information. It is not processed by the examiner, so it cannot be reconsidered. It has to be corrected again and then resubmitted.
Payment –After the approval from the examiner, company pays the provider. The healthcare providers usually have contracts with the companies. These contracts also include a certain fee for the billed services. This fee is provided to the healthcare provider. Sometimes the amount of the payment is reduced. It is reduced because of some conditions in the insurance policy such as coinsurance or copay.
Once the payment is done, the hospital or clinic will receive the statements of Explanation of Benefits (EOB). This statement is sent by the company. This whole procedure must be followed by the regulations of Health Insurance Portability and Accountability Act (HIPAA).
This process has some steps:
Checking eligibility – Before the treatment, the healthcare provider checks the eligibility of the patient for that treatment. They check it using computer software with the insurance company. If the patient is eligible according to the software, they provide the services.
Generating the codes – When the physician treats the patient, some procedure codes are generated and assigned to them. These codes carry the information of the diseases and treatment received by the patient. These codes are useful for the insurance companies. They calculated the coverage with the help of these codes.
Developing the form – After the codes are generated, the biller collects these codes and develops the claim.
Submitting – After deciding the codes, the claim will be submitted to the company by the biller.
Processing – Claims get processed at the company by their experts and examiners. They review, evaluate, and process them. When it comes to the higher payments, these companies take the help of medical directors.
Failed – Sometimes when the examiners review the claim, they do not find them payable. In that case, the form is returned to the healthcare provider. In this situation, there are two types, one is rejected, and the other is denied. A denied claim is usually reviewed by the expert of insurance companies. If the expert does not find it payable, he denies it. In that case, it can be reconsidered after making some correction. The rejected one is cancelled by the examiner because of some major error in the form or the information. It is not processed by the examiner, so it cannot be reconsidered. It has to be corrected again and then resubmitted.
Payment –After the approval from the examiner, company pays the provider. The healthcare providers usually have contracts with the companies. These contracts also include a certain fee for the billed services. This fee is provided to the healthcare provider. Sometimes the amount of the payment is reduced. It is reduced because of some conditions in the insurance policy such as coinsurance or copay.
Once the payment is done, the hospital or clinic will receive the statements of Explanation of Benefits (EOB). This statement is sent by the company. This whole procedure must be followed by the regulations of Health Insurance Portability and Accountability Act (HIPAA).
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