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How Medical Insurance Claims Are Processed

Since the cost of medical expenses are getting to be expensive, it will be difficult to be sick and hospitalized, especially if you don’t have much financial resources, and that’s why most people are into health insurance in order to reduce the impact of medical expenses, and since payment coverage of health insurance is affordable since you pay premiums either on a monthly or annual basis, more and more are subscribing in it.

When a health insurance subscriber wants to make use of her insurance benefits for medical treatment, hereby are the procedures which she will have to observe: the subscriber hands over her insurance card and fills out a demographic form at the healthcare provider’s office or clinic, and the demographic form requires the following data: 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, if the policyholder is someone other than the subscriber/patient; also, the subscriber or patient presents a government-issued photo ID.

After completing the paperwork, she proceeds for consultation and treatment on her health concerns with the healthcare service provider or otherwise referred to as the physician, which after a series of consultations, treatments, and tests, all chargeable costs are going to be documented by a medical biller and coder of the healthcare service provider, to which this document is called the medical bill or 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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Without a clearinghouse, the health insurance company of the patient may possibly act on these possibilities, as soon as it receives 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. 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.