Understanding the Process of Filing Health Insurance Claim

Submitting payment claims to an insurance company or to a state agency is primarily a job of the healthcare services provider. However, if you are interested in understanding the claim submission process then let us guide you thought the whole process.

There are certain types of insurance plans and patients have different coverage plans. There can be some similarities in government-provided coverage but there are numerous private insurance companies and each one of them has multiple insurance plans. From the insurers’ perspective, some plans require a monthly subscription fee to pay, some plans are designed with deductibles and others require copays. Therefore, it looks a challenging task to summarize in simple steps that how to submit an insurance claim form when there are multiple variables that determine the path to successfully submit payment claims.

So let’s summarize: how can you submit your health insurance claim and what’s the standard procedure? 

To claim a medical payment from an insurance company, you are required to fill a specific form and submit according to the requirements for the reimbursement of payments. In accordance with the HIPAA regulations, payment claims must be submitted electronically until you represent a small practice fewer than 10 employees or there are some other reason that is preventing from electronic submission. There are CMS-1500 and CMS-1450 types of claim forms that are generally used to submit payment claims manually.

Things You Need to Gather Before Submitting a Health Insurance Claim Form

To submit the health insurance claim form you will need some important information to fill out and also you have to understand the process. You will need different information to fill out the form of a health insurance claim and all these things are given below. Healthcare providers provide multiple services to patients and claim the cost of those services; you must enter precisely what medical procedure was performed against a diagnosis, personal information of the insurer, cost of the procedures performed and other ancillary details.

Claim Submission

After preparing the claim, usually, physician billing service sends it to a clearing agency for further scrubbing. Once cleared, the claim is sent to the specific insurance company for payment approvals. The insurance company either approves the claim, reject it or completely deny the payment. Copy of the submitted claim comes back to the sender with an explanation of the balance.

Claim Status

Your claim can be rejected by the payer on various grounds. Most insurance companies reject claims due to errors in it, so they point out those errors and reject it. It is now the job of the biller to correct those errors or fill missing pieces of information and submit again for approval.

There are some common billing errors that can cause rejection or denial, for instance:

  • Errors in the patient’s personal details which includes Name, Insurance Number, Sex and DOB

  • Incomplete provider information

  • Entering the wrong ICD and CPT codes

  • Missing diagnostic or procedural codes

  • Duplicate billing

  • Upcoding

  • Under coding

  • Incomplete or illegible documentation

  • Lack of medical necessity

If the biller has not well prepared a medical bill then the chances increase of its rejection. Avoiding all the above instances can save the claim from being rejected. A biller must understand the minute details and must follow all the instructions provided by the insurance company. Sometimes, there are changes in the process or update in coding requirements. Therefore, the biller should stay vigilant of the latest updates and prepare the claims accordingly.

Claim Scrubbing

If the claim is denied then it means that there are some errors that deem it impossible to pay. Biller can appeal the rejected claim but this is a long process and it becomes very difficult to get the approval of the rejected claims. Therefore, before submitting the payment claims, the biller must evaluate it from every angle and should make sure that there is no critical error that can cause a denial.

Timely Submission of Claims

The process of submitting claims must start right after a patient’s visit. The efficient claim submission process is the key to get maximum collections. The process should also coincide with efficient communication with the insurance company. If something is required by the payer after the claim submission, be quick to respond it and fulfill every requirement. Make sure that everyone in your team is proactive and they are open to queries and negotiations. Although there can be problems after taking all the precautionary measures and a dispute can arise. However, try to resolve the disputes with the payer as early as possible because delaying the settlement adds up additional expenses.

Filing health insurance claims on behalf of patients is a very important task and requires the intervention of physician billing service. Only a professional medical biller can understand the little details and prepare the claims accordingly. Healthcare providers must have onboard a trained staff or outsource the process to a medical billing company to get good results because the collections and revenue of an organization depend on optimized payment collections.

About RJ Frometa

Head Honcho, Editor in Chief and writer here on VENTS. I don't like walking on the beach, but I love playing the guitar and geeking out about music. I am also a movie maniac and 6 hours sleeper.

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