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Claims Processing: How Claims Are Paid

The claims process starts when a service is rendered to a patient who has medical insurance. Once the service is provided, the patient may be responsible for some out of pocket expense, but the rest will be paid through insurance and will involve communication between the medical practice and the patient’s insurance provider. Here, we’ll discuss how those medical bills (or claims) get paid.

Invoice with pen and calculator; document is mock-up

Who is responsible for Billing?

Medical practices are responsible for billing the insurance company when the patient has an HMO, government sponsored plan like Medicaid or Medicare, or when the patient has a PPO and the medical practice is in the patient’s network. The medical practice should have a department that is in charge of creating bills by adhering to claims filing policies (which may be insurance-specific), and by assigning codes for each service rendered to the claim. Claims contain medical billing codes as well as patient identification information, and are submitted to the patient’s insurance in order to receive payment.

Once the insurance company receives the claim, they will look it over for errors and choose to do one of the following:

  1. Accept the claim and pay the full amount requested.
  2. Deny the claim due to errors and return it to the practice for correction.
  3. Reject the bill due to an incompatibility of benefits.

It’s important that claims are submitted correctly in order to get an accurate, timely payment. Services offered by us at Apex EDI can help you! We’re a third party clearinghouse that verifies claims before they get sent on to insurance companies. Having a third party clearinghouse allows medical practices to spend less time, money, and manpower on their medical billing while avoiding the costly mistakes that are often made through the complicated process of filing. Request a demo today and take the mystery out of medical claim filing.

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