The Basics of Preparing and Processing Health Insurance Claims

Medical billing and health insurance claims can be complicated and time-consuming processes. Understanding the typical workflow of claims preparation and processing can help providers and their staff save time and maximize their reimbursements.

Gathering Initial Information

The first step in the process of preparing and processing health insurance claims is gathering the patient’s information. This involves collecting the patient’s name, date of birth, insurance provider, policy number, applicable copayments, date of visit and diagnosis codes for services provided by the provider. The information is then entered into the provider’s billing system, where it is used to generate the patient’s claim form.

Filing the Claim

Once the claim form has been generated, it is submitted to the patient’s insurance company. The claim can be submitted electronically via the provider’s billing software or it can be mailed or faxed to the insurance company.

Review and Payment

The insurance company will then review the claim to ensure it is accurate and eligible for payment. The review process can take a few days, and it may be necessary to submit additional information or documentation to the insurance company in order to receive payment. Once the claim has been approved, the insurance company will issue payment to the provider.

The Bottom Line

Health insurance claims can be complex and time-consuming processes, but understanding the workflow can help providers efficiently prepare and process claims and maximize reimbursements. Providers should ensure that the initial patient information is correct and complete, file the claim in a timely manner, and be prepared to provide additional information or documentation as needed in order to receive payment for services.