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Medical Claims vs. Vision Care Claims

When handling claims regarding eye health, there are a few things to be aware of. For example, there are specific differences between what can be billed to a vision plan and what should be billed through medical insurance. Let’s discuss the difference between the two claims, and why eye care professionals need to know the difference.

girl with glasses

The Difference

Vision plans cover routine wellness exams for eye health. This means examinations for near- or farsightedness, astigmatism, and corrective lenses. Medical eye care on the other hand is for the treatment of specific medical conditions related to the eye, such as pink eye, cataracts, double vision, etc.

Why It Matters

As we discussed above, vision plans cover annual exams for eye health. When an exam reveals a condition such as pink eye, cataracts, glaucoma, dry eye, or another condition, the diagnosis and treatment is billed through the medical eye care insurance. A medical eye condition typically requires a more intensive treatment plan than what is covered through a run of the mill vision plan, which is why medical insurance typically steps in.

As the provider, you will want to ensure that you are billing the correct insurance in order to receive the fees you are due. Many eye care professionals bill the vision plan first, and then reach out to the medical plan if any fees have yet to be covered. It is also important to discuss the plan of action with the patient so that they are aware of how the services will be billed to their insurance and that they are aware of any fees that may accrue due to their specific plans.

The Solution

In order to ensure the best possible care for your patients and management of your optometry practice, implementation of a clearinghouse for claims billing is recommended. A clearinghouse verifies vision and medical claims before they can be sent to the payer for final submission.

Apex EDI is a user friendly and fully integratable clearinghouse that works to get you paid faster. For more information about how Apex EDI can be used to benefit your optometry practice, click here.

Posted in: EDI, Medical Claims, Opthamology Claims, Optometry Claims

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Why You Should Use Dental Billing Software

Smiling woman at dentistAs a dental provider, you wear a lot of hats. Dental claims billing might be one of them. Let’s discuss why it will be beneficial for you and your dental practice to consider using a dental billing software, such as Apex EDI.

Specialized Software

Dental claims codes are completely different from standard medical claims codes. Dental billing software is designed specifically for dental claims billing. Without an efficient software to integrate with your practice management system, you’re risking increased opportunities for errors, missed claims, or denied payments.

Apex EDI dental software integrates with your existing dental practice management software to create properly completed dental claims to be billed to payers. Apex EDI will alert the dental claim preparer of any errors that may be present on the claim to be submitted. Such errors might include a typo, or an absence of other information such as x-rays.

Faster Processing

With the right dental billing software, your practice can get paid more quickly. Traditional dental claims filing through the postal service or through fax or email can take weeks to process. A dental billing software allows claims to be processed in significantly less time.

For example, Apex EDI provides real time information on the claims processing progress. Not only will you be able to view patient eligibility and benefits within minutes, you’ll also be able to process dental claims faster and more efficiently.

Faster processing means faster payment for your dental practice, so you can focus on providing exceptional service to your patients.

Cost Savings

Another benefit of using a dental billing software is the cost savings that is associated with the practice. Dental billing software traumatically cuts down on the physical paper trail of information, as well as postal service and shipping expenses to send claims to the payer.

Apex OneTouch (the desktop app) allows for the seamless integration of your existing dental practice management software with the EDI to provide exceptional cost savings and efficiency for your dental practice.

For more information on Apex EDI for Dental Practices, be sure to check out our Dental Claims page.

Posted in: Dental, Medical Claims

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How Do Medical Claims Work?

medical expensesThe medical claims industry is only a small part of the trillion dollar healthcare field. However, it is arguably one of the most important aspects for providers, as the medical claims process allows physicians and practitioners to maintain their clinics and businesses by receiving payment for their services. Let’s take a look at how medical claims actually work.

Services Rendered

The first step is for a patient to request services from a healthcare provider. The healthcare provider then grants services to the patient, be it in the form of a physical exam, diagnostic procedure, or any other billable service.

Each service is recognized in the medical industry with a unique code specific to that service. When the physician completes the patient report, the report will be submitted to medical claims with the appropriate medical codes for the services rendered.

Processing The Claims

The next step is to process the claims. This can be completed via traditional methods, such as fax or postal service. However, many practices are now implementing electronic claims processing, as it is significantly more cost effective, efficient, and secure than traditional methods.

The claims preparer examines the physician’s report on the patient. The preparer verifies that the claims codes are correct for the services that were rendered. The preparer creates the claim that will be sent to the insurance provider for that specific patient. The preparer might use a software such as Apex EDI for secure and efficient transfer of documents to the insurance company.

The claim is then processed by the insurance company.

Payment, Denial, and Appeals

Once a claim is processed, it is either approved or denied. A claim can be denied for a variety of reasons. The reason for denial could be as simple as the insurance company requesting more information before approval, or it could be that the service rendered is not an eligible service under the patient’s insurance coverage.

When a claim is approved, the insurance provider issues payment to the clinic or physician that submitted the medical claim. When a claim is denied, it may be resubmitted by the preparer, or the patient can appeal the denied claim to their insurance company. Typically a denied claim will require out of pocket payment from the insured patient in order to cover the cost of services rendered. However, a few exceptions have been made through lengthy appeals processes.

While medical claims billing might seem like a fairly straightforward process on the surface, there is a bit more to it than this article can provide. If you would like to know more about the medical claims billing process and how this aspect of your business can be streamlined with an EDI software, be sure to reach out to us by filling out the contact us form here. The professionals at Apex EDI will be happy to assist you with any questions you may have about improving your medical claims process.

Posted in: Medical Claims

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Top Reasons to Use A Medical Billing Company: Cost Savings and Consistency

As a healthcare provider, you wear a lot of hats. Medical billing might be one of them. Let’s discuss why it will be beneficial for your healthcare practice to consider outsourcing billing practices to a professional medical billing company.041019-N-5821P-019

Cost Savings

The cost savings associated with using a medical billing company as opposed to completing billing in house is significant. A study completed by Physician’s New found that the typical cost to process medical billing procedures in house is approximately $118,000 per year. The cost of billing department costs per year when the practice of medical billing is outsourced? $4,000.

That’s less than 1/30 of what your healthcare practice would pay if you continued to process medical billing in house. In addition to significant billing department costs, your practice will also be able to collect up to 5-15% more of billings processed. While that might not seem like much now, it can add up into a significant profit over the course of a fiscal year.


Another reason to use a medical billing company is the consistency you will experience. Consistency in the form of denied claims appeals, staffing requirements, and various other processing practices for medical claims and billing procedures.

The professionals who are employed by the medical billing company you choose to outsource your billing procedures to are experts in their field. They know exactly what needs to be completed in order to process claims quickly and efficiently. Not only will they be able to uphold industry standards, the medical billing company will be able to efficiently adhere to changing standards and legislation in the field.

Apex EDI is a great method of streamlining your process with medical billing. In order to ensure that medical claims are billed properly and efficiently, consider utilizing the software integration behind Apex EDI. Apex OneTouch, the desktop app, integrates seamlessly with over 30 practice management softwares to ensure fast, efficient, and accurate billing for you and your medical billing provider.

For more information, visit our products page.

Posted in: EDI

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Why Use EDI in Healthcare?

As the digital world continues to advance, we are privileged to use various software and technologies that make our jobs easier. Once such technology is electronic data integration (EDI). EDI allows for improved healthcare claims processing, including better security and efficiency for patients and healthcare providers.Patient and medical staff


EDI allows for improved security and privacy measures for healthcare claims processing. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 protects patient’s privacy and provides boundaries as to whom medical records can be released to. EDI minimizes the possibility of information over sharing when it comes to medical records and health care claims submissions.

For example, traditional information sharing through paper claims mailed through the postal system or information emailed to an individual increased the chances that more individuals than necessary came into contact with the private information. While these individuals may have clearance to handle this information, it is an inefficient and insecure method of information sharing.

EDI, on the other hand, specifically integrates with a health management system within your healthcare practice to minimize information handling and claims processing. Instead of passing patient information from person to person (or email to email), the EDI software passes the documents through a securely integrated system that is based on specifically coded transactions.

These transactions can only be viewed and processed by another EDI system that can read the agreed upon standard formatting of these coded documents. This ability to share documents and information between EDI softwares that only accept certain codes increases the security of patient information and healthcare claims.


Efficiency is another great reason to use EDI in healthcare practices. EDI significantly decreases the amount of time it takes to submit and process a claim. Not only will most EDI’s help you to identify potential mistakes within the claim to be submitted, it will also assist in the processing by providing real time feedback about the claims submission.

Efficiency in processing allows for healthcare claims to be processed faster, meaning healthcare providers can get paid for services rendered more quickly through an EDI software.

Though security and efficiency are important aspects to any software within a healthcare practice, it is critically important within an EDI. For more information about plans and pricing of Apex EDI software, reach out to us on our Contact Us page. Security and efficiency are of utmost importance to our professionals at Apex EDI. We will be happy to assist you in incorporating a secure and efficient medical claims software into your practice.

Posted in: EDI

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