Claim processing
The insurance company processes the claims. The insurance company has medical directors review the claims and evaluate their validity for payment using rubrics for patient eligibility, provider credentials, and medical necessity. Approved claims are reimbursed for a certain percentage of the billed services. These rates are pre-negotiated between the health care provider and the insurance company. Failed claims are rejected and notice is sent to provider. Most commonly, rejected claims are returned to provide in the form of (Explanation of Benefits) EOB or Remittance Advice. Upon receiving the rejection message the provider or the medical billing company must decipher the message, reconcile it with the original claim, make required corrections and resubmit the claim. This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, or the provider relents and accepts an incomplete reimbursement.
As a payer organization, it is essential for you to augment your health insurance claims processing process structure and reduce operating costs. Healthcare claims processing outsourcing and accuracy in health insurance claims processing are the key elements to improving your turn-around time and claims output. Continue reading ‘Claim processing’ »