Most healthcare services are paid by third party payers in the United States. This includes Medicare, Medicaid other government services and private insurance companies.
The health insurance company will receives the claim and will start the initial processing review. Then insurance company will look for common errors and missing information. When errors found,the claim may be rejected and it can be resubmitted with the correct information. For example, spelling of the patient name or a missing diagnosis code is found, it will be rejected and needs to be resubmitted with necessary corrections.
If the claims are submitted electronically, the initial processing may be done by software and kick out those that are incomplete or appear to have errors.
As a next step it goes for a review to check the claim against the insurance payer’s payment policies. Here procedural and diagnostic codes are examined, and physician's NPI designation is checked. At this point, if the claim passes, it will be paid, and the remittance advice may be issued to the physician and patient.
Some claims are sent for a manual review by medical claim examiners, which may include medical professionals and a check of the medical documentation. This is more likely to be required for unlisted procedures in order to confirm that they were medically necessary. This part of the process may take more time as it involves obtaining the medical records.
The health insurance company will receives the claim and will start the initial processing review. Then insurance company will look for common errors and missing information. When errors found,the claim may be rejected and it can be resubmitted with the correct information. For example, spelling of the patient name or a missing diagnosis code is found, it will be rejected and needs to be resubmitted with necessary corrections.
If the claims are submitted electronically, the initial processing may be done by software and kick out those that are incomplete or appear to have errors.
As a next step it goes for a review to check the claim against the insurance payer’s payment policies. Here procedural and diagnostic codes are examined, and physician's NPI designation is checked. At this point, if the claim passes, it will be paid, and the remittance advice may be issued to the physician and patient.
Some claims are sent for a manual review by medical claim examiners, which may include medical professionals and a check of the medical documentation. This is more likely to be required for unlisted procedures in order to confirm that they were medically necessary. This part of the process may take more time as it involves obtaining the medical records.
