Steps in the Health Insurance Claims Process

The health insurance claims process is important to understand. Every insurance company has their own process, as well as every state. You can imagine how difficult it is to format millions of patient claims in a thousand different ways.
This is why most medical practices utilize clearinghouses. A clearinghouse helps with the submission of claims. This is beneficial for the patients as well as the providers. Patients benefit financially as their insurance covers a portion of their procedures, while healthcare providers receive prompt payments. A health insurance claim entails many steps.
The insurance provider process is as follows.
A claim receipt is created when the insurance provider receives the claim from either the healthcare provider itself or a clearinghouse.
Once the receipt is made, it starts the reviewing process. This is called an initial review. Here, the claim is checked for completeness and accuracy. This is where the basic information such as patient details, provider details, and service dates are verified. This verification process can take anywhere from a few days to two weeks.
Once this information is verified the next step is checking whether or not the treatment is medically necessary. Being medically necessary means evaluating if the treatment is significant to the patient's health or not. If it is the claim will continue along in the process.
If it is not, you have to appeal the claim. There are many ways to appeal claims. Submitting additional documentation is just one way this can be done.
The pricing and payment decision is the next step. This is the most important step since this determines if the claim will be approved or not. Deductibles, co-pays, and co-insurances are also calculated during this step.
Once the insurance provider pays the claim, it is classified as closed and sent to the provider.
Remittance is when the payment is received by the provider. This is where statements are created for the remaining amount due. A statement tells the patients what the insurance covers, how much they owe, and when the payment is due. Clearinghouses oftentimes aid healthcare facilities create these statements.
When the statement is paid, it is considered complete and does not require any more attention from the insurance provider or the healthcare provider.
However, it is hard to get to this step. Many patients take longer to pay their bills or need reminded. Clearinghouses also aid in this process.
Clearinghouses facilitate accurate submission and processing of claims. This reduction in errors is essential for healthcare provider's profits and for streamlining the insurance process.
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