Preparing the Insurance Claim

The Insurance claim is prepared after the patient completes the medical treatment. The medical coder uses the information on the medical history of the patient already recorded in the system and determines the patient’s diagnosis, treatment and procedures as prescribed. It is then coded using ICD and CPT codes into a formal claim. The claim is further reviewed to establish the compliance with the insurance policy. These requirements differ from patient to patient and on the medical provider and the health insurer.

Review Coding Compliance

Coding is the primarily task where the diagnosis and medical procedures are described using CPT and ICD standard codes. However, many times the codes are corrected based on juxtaposition of different medical conditions. The guidelines are further specified for special medical diseases such as those related to heart or kidneys. Satisfying the medical guidelines becomes important at this time to correctly code the patient’s medical information. Only the proper medical documentation results in fast approval of the insurance claim. When done according to official guidelines, it becomes easier for the insurer to examine the claim and pass it for reimbursement. The medical insurance specialist should be certified which ensures basic medical knowledge and should not resist from taking advice from a medical expert to form a correct code.

Check Billing Compliance

There is standard fee schedule related to each medical procedure and service. Each service is properly documented using procedure code. It is important the medical biller to take notice that each code is connected to the medically necessary treatment and thus is billable. Most of the insurance policies cover the medically necessary services. Thus, it becomes the sole duty of the medical insurance specialist to properly assign procedure code so that proper billing can be done. Since medical services are covered differently by various insurance policies, the medical insurance specialist should check and review the codes properly. Some codes are only billable when they form part of the medically necessary treatment to the patient. The biller should take notice of this and add the code only if it is billable. The redundant information can only lead to confusion and denial of claim. The biller should look for specific codes provided by the payer which can interlink the diagnosis and treatment which can be reimbursed.

Preparing the Insurance Claim

Preparing the Insurance Claim

Prepare and Transmit the Claim

Once the claim is properly prepared, it is sent to the insurance company for reimbursement. The claim includes the information about the medical services and procedures which are billable to the insurer. A properly documented insurance claim is often reimbursed at earlier time. The health care facility usually transmits the claims electronically. Additionally, the medical insurance management software allows interaction among the claims examiner and the medical insurance specialist for any impending questions regarding claims. The medical software can help maintaining database of many patients which can be easily used and retrieved saving time, effort and money to the facility.

Some health care facilities employ services of a clearinghouse. A clearinghouse can have contracts with various health facilities for approving their claims from different insurers. It employs certified staff well versed with different insurance policies and with use of latest technology is more efficient in dealing with the insurance claims.

Final preparation of insurance claim
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Final preparation of insurance claim
Before sending a medical claim to the payer, it is further reviewed to establish the compliance with the insurance policy.
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  1. Deandra June 30, 2017

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