News & Events

Medical Claims Processing Laws

Between dealing with physician, patient, and insurance data, staff in your billing department will be handling a lot of sensitive information. This is why it’s important for everyone in your billing department to understand the laws protecting that information and what they and the practice are responsible for, when it comes to the laws surrounding medical claims processing. Here are just two of the most important medical compliance agencies that medical billing specialists should be aware of.


HIPAA Regulations documents on a desk apex edi

Many people are at least aware of the existence of HIPAA, a set of guidelines that governs the way that medical information is protected. While HIPAA covers many aspects of patient protection, the part that applies most pressingly to those working with medical claims is found in Title II, which governs how and with whom patient data can be shared. HIPAA simplified the process of medical billing by providing universal identifiers for providers, employers, and patients, and by standardizing the requirements for electronic claims processing software.

Billing staff will be required to stay in compliance with HIPAA by protecting patient information and not sharing it with unauthorized parties. Medical practice employers should review HIPAA with all of their employees during the onboarding process.


The OIG was established to enforce HIPAA and prevent medical fraud. To remain in compliance with OIG, it’s important that medical billing staff refrain from activity that may be considered fraudulent. Fraudulent activity is generally classified as purposely falsifying information for benefit. At its worst, this involves practices providing false information on a patient’s medical record for financial gain. The OIG investigates and prosecutes practices that are found guilty of this type of behavior.

Best practices as outlined by these guidelines will help you keep yourself, your patients, your employees, and your practice safe.

At Apex EDI, we’re dedicated to making the medical claims process easier and helping medical practices get back to helping patients. We’re experts in medical claims processing policies and laws. We can help you better manage this confusing but important part of your practice.  We provide your practice with the tools and assistance necessary to cut down on claim denials and simplify medical claims filing.  Want to learn more? Request a demo today.

Posted in: Apex EDI, EDI, Medical Claims

Leave a Comment (0) →

How to Bill Dental Claims

Filing dental claims can be somewhat unique to filing other kinds of medical claims, but it’s important that dental practices file these claims for their patients in order to remain competitive. We are going to help you to learn what you’ll need to do to file these dental claims so that your practice can get paid and your patients can get the help that they need.

Record and Maintain Patient Information

Dental Claims Apex EDI

You will need a fair amount of patient information when formulating a dental claim. Ensure you have accurate information from the start by asking the patient for this information as soon as they make the appointment. Make sure that you are asking the patient about changes to their information at consecutive appointments so that you never have to deal with a denial due to incorrect patient information.

One way to ensure patient information is collected correctly and in a timely fashion is to collect patient information over the phone at the time the appointment is made. Create forms or spreadsheets that help track the information and remind the person collecting it what data is required. Alternatively, a form can be made for the patient to fill out prior to the appointment once they arrive at the office.

What You’ll Need

You’ll need to collect the following pieces of information:

  • Patient’s name
  • Policy holder’s name and social security number
  • Name, address and phone number of the insurance company
  • The policy number

If the insurance is through the policy holder’s work, you’ll need the employer’s name and address as well.

Determine a Billing Process and Draft an Agreement

It’s important to establish policies for filing dental claims from the beginning, and keep these consistent throughout your practice. Determine how many times you will bill insurance, or how long you will wait before sending a bill to the patient for unpaid amounts.

Once you have determined your billing policies, you’ll need to draft an agreement informing your patients of these policies. This should be signed by the patient before any services are administered, and should be retained in the patient’s record. Be sure to inform patients that they will be held responsible for any unpaid medical bills.  

Ensure Claims are Filed Accurately (or Let Us Do It for You)

It’s important that claims are filed accurately so that your practice can get paid in a timely manner. But navigating the complexity of claims can require more time, money, and manpower than is feasible for many dental practices. Simplify the process by hiring Apex EDI, a clearinghouse that provides you with the tools and assistance you need to save time, cut down on claim denials, and run your billing department efficiently. See how Apex EDI can benefit you and your patients by requesting a demo today.

Posted in: Apex EDI, Dental, Dental Claims

Leave a Comment (0) →

How to Review Medical Claims

The medical claim review process can be tedious, time consuming, and even stressful due to a system that is often complex and demands accuracy. However, reviewing your claim denials and rejections on a semi-regular basis can save your practice time and money in the long run by reducing the number or denials that you have to deal with in the first place. Here are some of the things you should be doing on a monthly basis to ensure that your medical billing is running as efficiently as possible.

Young doctor explains how to fill out a medical form. Partnership, trust and medical ethics concept

1. Review Your Billing Register

Analyzing your billing register will help you find out how many bills you are have to rebill- and as a result, how many denials there have been. Subtracting the dollars billed out in a given month by your monthly charges will give you the amount of money that has been rebilled over the course of that month, and you’ll start to get an idea for how efficiently your system is running over all.

2. Review Paper Denials and Electronic Explanation of Benefits

The next area to review should be the paper denials and E-EOBs (Electronic Explanation of Benefits) your practice receives. This should give you an idea of why claims are being denied, and help you identify frequent problems such as illegibility of the claim or codes that are frequently reported in error.

3. Identify Recurring Issues

Once you have a good idea of how many claims are being denied and what the reasons are for them, you can start to identify patterns in your denials. Are members of your billing staff writing off some accounts that they shouldn’t be? Are claims being denied due to missing information or missing signatures? Are members of the billing staff selecting incorrect or out of date codes?

Any of these mistakes or many others could be contributing to higher volumes of denials or other billing issues, wasting your practice’s time and money. Identifying these issues early allows you to make adjustments that will make your medical claims billing run more efficiently.

Tired of investing so much time, money, and manpower into your claims filing process? Simplify it by hiring a medical clearinghouse that offers the tools and assistance you need to run your billing department stress-free and with fewer errors. Request a demo today to see how Apex EDI outshines other services and allows you to get back to work helping your patients.

Posted in: Apex EDI, EDI, Medical Claims

Leave a Comment (0) →

How Claims Are Authenticated

Payment for medical services can be a complicated process due to the involvement of a third party (insurance) with interests of its own. You may already know what the process of submitting a medical claim is like, but what happens after the claim leaves your desk and is sent on to the insurer? Here, we’ll discuss the standards set forth by medicare for authenticating medical claims, standards that are typically followed by other insurers.

What has to happen before a medical claim can be processed?

Medical Billing Process

Before a medical claim can be processed, it must first be authenticated through a rigorous process of signature analysis. This process is important for physicians and medical practices to understand so that they can submit authentication materials properly. What does an insurer look for in claim authentication?

First of all, any service that is provided or ordered for a patient must be signed for by the ordering practitioner, and this signature must be handwritten, electronic, or in the case of physical disability, stamped. Electronic signatures must come from a system that is protected against modification and signatures used to prescribe medication must be submitted through a qualified e-prescribing system. The signing physician and practice are responsible for the authenticity of the signature.

All signatures must be legible so they can be identified by those reviewing them. Failure to provide a signature or the presence of an illegible signature will result in the medical practice being assessed an error. If there is a failure to sign, the medical practice may submit an attestation statement from the author of the medical record, or progress notes showing intent to order tests.

If a signature is illegible, submitting a signature log may resolve the issue. A signature log is a document that contains physician names with their corresponding unique signatures, and can be used to establish ownership of a signature. Submitting a signature log initially may help reduce delays going forward.

It is very important that all medical claims can be accurately authenticated to avoid unnecessary services and overpayments. While this process may seem lengthy, it protects the patient, physician, practice, and insurer.

Filing medical claims can be a stressful process that weighs heavily on the staff of any medical practice. It doesn’t have to be, though. Simplify your medical billing and avoid costly, time-consuming errors by hiring a clearinghouse like Apex EDI. Apex EDI has everything you need to effectively file medical, vision, dental, and chiropractic claims without putting such a strain on your practice. Request a demo today, and see what a difference the right clearinghouse can make.

Posted in: Apex EDI, Medical Claims, Resources

Leave a Comment (0) →

How to Write a Claim Letter

A health insurance claim letter is a letter a claimant writes to a health insurance company if the claimant’s doctor has not properly filed a medical claim. This letter typically seeks for a reimbursement to the patient after the patient has already paid their medical bill, per the agreement between the claimant and the insurer. It is only effective if the services in question are covered under the claimant’s insurance, and is not intended to be used to seek reimbursement for items not usually covered.

Who is responsible for submitting the Claim Letter?

Mature Woman Reading Letter After Receiving Neck Injury

The claimant will be responsible for paying any deductions necessary, and these payments will not be reimbursed. As well, the claimant needs to be aware of all documents and forms that must be included in the claim, and they must correctly fill out and submit these papers. While these may be different from one case (or one insurer) to another, the basic forms should include the following:

  • The completed claim form
  • Any bills for services rendered such as prescriptions, treatments, or tests
  • Receipts for medical bills
  • Hospital discharge papers
  • Surgeon’s bill (if relevant)

If your insurer requires original copies of these documents, it’s wise to retain copies. Any additional documents supporting the claim may be helpful even if they are not strictly necessary.

The letter itself should be short and contain only the details of your request and your insurance policy number. The letter should cite the terms of the policy that apply to claim. Most insurers require that you submit these claims within 7 days of completion of treatment, so timely submission is important.

At Apex EDI, we’re interested in taking the mystery out of medical billing, and making it easier for everyone. Our medical clearinghouse services are to help simplify the medical claims process, and save medical, dental, vision, and chiropractic practices time and money that they can put towards taking better care of their patients. Want to see what our company can do for your practice? Request a demo today, and stop doing claims the old fashion way.

Posted in: Apex EDI, Medical Claims, Resources

Leave a Comment (0) →
Page 1 of 23 12345...»