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Claims Processing: Why Doctors Should Monitor Medical Claim Status

Doctor fees

Most doctors have experienced some medical claims headaches at some point in time. The routine monitoring of patients’ medical claim status can help you prevent potential problems or claim denials before they occur. The likelihood that you will ever receive a payment drops significantly if your claim is denied once.

You can save a lot of time by using an electronic medical billing software system. Electronic transactions and standardized reports make it much easier to ensure payments for health services are accurate. Automated computer billing rules can spot problematic claims before they are submitted.

Then, of course, no one likes to follow up on late payments, but if you delay you are much less likely to receive full payment for services rendered. Medical billing software can simplify the process of tracking receivables and monitor underpayments to ensure that you follow up quickly. It also ensures that you stay compliant with ICD-10 regulations.

A good software tool gives you the ability to spot problems at a glance. You will be able to catch errors, see the status of all claims and know when you need to follow up right away. We want to make this process easy for you and free up your office staff’s time to care for patients.

At Apex EDI our supportive, highly skilled staff is always ready to assist you. We want you to get paid on time for every patient’s medical claim. Contact us at Apex EDI to request a software demonstration today.

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Medical Claims Processing: 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.

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Claims Processing: 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.

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Claims Processing: 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.

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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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