Medical Claims

What are medical claims?

Medical claims are bills or requests for payment that healthcare providers submit to a patient’s health insurance provider. Hospitals, doctors, clinics, and other healthcare facilities turn in these requests following the services and treatments they provide to patients. Medical claims contain unique codes that detail the care and treatment a patient receives.

Healthcare claims management software makes the medical claims process leaner and expedites the patient’s payment process between healthcare providers and insurance companies. Payers, healthcare providers, and insurance providers use these software tools to prevent or quickly resolve disruptions to the claims processing lifecycle. 

Types of medical claims

There are different types of medical claims depending on the service provider, type of treatment, and health insurance plans. Some of the common types of medical claims are listed here.

• Professional claims: Doctors, specialists, surgeons, and other healthcare providers submit professional claims. Some examples of services include office visits for physicals, consultations, surgeries, and diagnostic testing, such as blood tests.

• Pharmacy claims: Pharmacies submit claims for medications after a patient receives a prescription from a doctor. Depending on the type of healthcare plan an individual is on, insurance companies, government programs, patients, or some combination will pay pharmacy claims. 

• Hospital claims: Patients who receive an inpatient or outpatient service may receive a hospital claim. Hospital claims cover services like surgeries, emergency room visits, and room and board.

• Dental claims: Dental and orthodontic providers submit claims for dental services, such as cleanings, fillings, extractions, and orthodontic care. 

• Laboratory and diagnostic claims: Some facilities, like laboratories and radiology centers, offer specialized testing and imaging services. These facilities submit claims for blood tests, ultrasounds, and magnetic resonance imaging (MRI) scans.

• Ambulance claims: Ambulance services may submit separate ambulance claims for transportation to and from medical services during emergency and non-emergency medical situations. 

• Mental health claims: Therapists and psychiatrists submit claims for counseling, therapy, and psychiatric treatment services. 

Basic elements of medical claims

Medical claims contain specific details and documentation about a patient and their treatment to ensure accurate processing and reimbursement. Medical claims are typically split into two components: the claim header and the claim detail.

The claim header summarizes the most essential information about the medical claim, including basic patient information and the overall service charge.

As the name suggests, the claim detail is a specialized section of the medical claim that offers detailed information about a patient’s services or procedures.

The medical claims process

While healthcare providers may make slight variations to the claims process, there is a general process most medical claims go through to ensure proper processing and payment. The steps in the medical claims process follow:

• The patient visits the healthcare provider and receives care and treatment. 
• After the visit, the provider’s office submits the claim, physically or digitally, to the insurance provider.
• Once the insurance carrier receives the claim, they conduct a thorough review process, checking for accurate data and filing within an appropriate time frame. As part of the review, the insurance carrier verifies member eligibility and network status. 
• Once the insurance carrier verifies the member, network, benefits, and claim information, the insurance company decides whether the services and treatment are necessary for the patient’s medical needs.
• Then, the insurance company sends payment to the provider based on any negotiated rates they have with their networks. The patient receives an explanation of benefits (EOB) statement that details the total cost for all services, including how much the insurance carrier paid, and how much the patient still owes, if applicable. 

Best practices for filing medical claims

Filing medical claims can be time-consuming and complex, but following a general set of best practices guarantees that claims are processed efficiently. Below are some best practices for filing medical claims for healthcare providers:

• Double-check patient information for accuracy: Inaccurate patient information, including insurance details or contact information, can lead to claim denials. Providers must ensure patient information is accurate before submitting claims for review to stop unintentional hiccups in the process.

• File claims promptly: Delays in claim submission can lead to denials or partial payments. Providers should stay well-informed of insurance companies’ filing deadlines and timelines to avoid submitting claims at the wrong time. 
• Use proper coding: Obtaining payment for the right services and treatments requires correct coding. Medical professionals should regularly refresh their coding knowledge to stay up-to-date with changes.

Read about healthcare revenue cycle management and how it encompasses claims processing.