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Posts Tagged claims processing

Claims Processing: The 5 Keys to a Successful Claim

Apex EDI is dedicated to simplifying claims management. Laying a good foundation with some basics steps to a good claim can help reduce stress and lead to a better result, so we’ve gathered 5 helpful keys to successfully filing a claim.

Wooden Blocks with the text: Claims

1. Determine Your Priorities

The first step to successfully managing a claim is setting a goal for what you want to accomplish through the process. Does a larger settlement outweigh a faster one? Are you more interested in the claim being processed smoothly or are you looking to generate cash flow? Your goal for the claim will help you and your team make decisions throughout the process.

2. Have a Team of Professionals Ahead of Time

Your insurer has a team of experts who know how to reduce their responsibility to you as much as possible. Because of this, it’s important that you, too, have a team of experts that can help you evaluate the responsibility of the insurer to your benefit and combat the team that the insurance company has put together. Having these people available and organized before you need them is ideal.

3. Have a Plan

It’s important to have a well-laid plan of how you’re going to deal with claims ahead of time to ensure that all steps are taken care of and all requirements are met throughout the claims process. Talk to claims management professionals to help you develop your plan, and engage with them when you need to argue a claim.

4. Prioritize Your Claims

Claims take time and attention to process correctly. Prioritize your claims by investing your time and money on the front end so that you don’t end up paying for it over the long term. Having dedicated employment for such matters, or hiring a third party to help deal with it for you, will be your best bet in ensuring that you get what is owed.

5. Manage All Your Information

Incorrect or incomplete information can cause a claim to get dragged on for much longer than it needs to be. Ensuring that you have all the correct information up front and double checking for errors can save you a lot of time and money in the long run.

When filing medical claims, it’s important not to waste time on mismanagement of claims. Let the professionals at Apex EDI clearinghouse help you get better results faster, and with less expense to you. Our feature-rich claim filing programs will help you get the most out of your billing team and your filing software, all at a competitive price. Learn more about what we have to offer by contacting us or visiting our website.

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Claims Processing: 5 Things You Must Know About Denied or Rejected Claims

Denied and rejected medical claims result in substantial financial losses for medical, dental, and vision practices. This is why it’s important to stay vigilant about these denied and rejected claims and keep on top of resolving them. Here are a few things that you should know about these claims that will help your office better deal with them.

1. The Difference Between Denied and Rejected Claims

Denied and rejected claims are not the same. A denied claim is one that is determined unpayable by the insurance company. Sometimes these are due to error on the part of those submitting the form and sometimes it is due to patient ineligibility for services rendered. Either way, the insurance company will let the office know what the reason for denial was on the Explanation of Benefits (EOB).

These claims can be appealed, but it’s better to try and avoid these if possible. A rejected claim is sent back due to errors, and is simply resubmitted with corrected information. Because constantly appealing and re-submitting denials and rejections can be costly and time consuming, it’s worth investing time and resources into ensuring claims are filed successfully the first time.

2. The Most Common Reasons for Denials and Rejections

Insurance companies have very strict requirements when it comes to how claims should be filed. Some of the most common reasons for rejections include incorrect service or diagnosis codes, missing or incorrect patient information, and insurance specific requirements that aren’t met. Hiring a reliable clearinghouse, like Apex EDI, that can scrub for errors and keep track of insurance specific requirements will help you avoid these errors, and save you time and money in the long run.

3. How to Resolve Issues Quickly

Many claim errors are made because of imperfect or out-of-date information somewhere along the line between scheduling an appointment and submitting the claim. Small oversights such as failing to consistently ask patients about changes to their insurance or patient information during sign in, or failing to keep up to date with insurance-specific requirements can lead to many unnecessary denials and rejections. Communication is key to ensuring that the most correct information is always used on claims.

4. Trends in Your Denied and Rejected Claims

Keeping track of trends in denied and rejected claims can help you catch repeating issues. By digging a little deeper you may find that a specific code or repeated error may be to blame for a large number of denied or rejected claims, and you may be able to significantly reduce the time and money you spend on resubmitting by simply resolving the error for future claims.

5. How Apex EDI Can Save You Time and Money

Using a reliable, hard working clearinghouse can help you reduce administrative costs, reduce the number of denied and rejected medical claims you have to deal with, and save you the time and money that is often lost through mismanaged claims. We have a feature rich program that makes it easier than ever for you to file your claims and catch mistakes the first time. Click here to discover all the features we offer and to learn more about how we can help you get paid faster with fewer headaches.

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Medical Claims Processing: How Are Medical Claims Processed?

File Folder Labeled as Claims in Multicolor Archive. Closeup View. Blurred Image. 3D Render.

Once medical services have been administered to a patient, payment needs to be requested from insurance through appropriate channels. These requests for payment are known as medical claims, and to the lay person, filing them may seem rather complicated. We’re hoping to demystify this process by breaking down the way medical claims are filed and paid.

Each service rendered to a patient has a designated code so that the payer will be able to reference them against codes and services the patient is eligible for. These codes along with insurance and patient information make up the bill that is sent on to a clearinghouse on its way to the patient’s insurance provider. Medical bills are often processed and submitted through online channels because it saves time and money, but hard copies are still available and occasionally used for this process.

This is where Apex EDI comes in. Forms are sent through clearinghouses like Apex EDI before being sent on to the insurance company so they can be scanned for errors and reformatted to comply with HIPAA and insurance company standards. Clearinghouses like ours are necessary because each insurance company has different standards, and doctors offices are responsible for submitting high volumes of claims to different insurers on a daily basis. Without a clearinghouse, the strain on the billing department of the office would be astronomical.

The doctor’s office chooses which clearinghouse it works with, and it’s important to select one that works with the insurance companies you work with, can work with the software you have available, and is reliable. Luckily, we at Apex EDI work with many different insurers as well as many different software programs. Visit our website or give us a quick call to see how we go above and beyond to serve all of your medical, dental, and vision claims needs. Choose Apex EDI to help you get your claims filed faster, get paid faster, and take the stress out of the claims filing process!

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Claims Processing: Optometry vs. Ophthalmology

Trusting a doctor with eye care is an important health care decision. The type of eye doctor a patient uses is largely a matter of personal preference if the eyes are healthy and don’t require specialized medical or surgical treatment. There are two types of eye doctors: optometrists and ophthalmologists. Both perform routine eye exams and are trained to detect, diagnose and manage eye diseases that require medical and non-medical treatment. Apex EDI handles both Optometry and Ophthalmology claims.

an eye

An optometrist is an eye doctor who has earned the Doctor of Optometry (OD) degree. Optometrists examine eyes for both vision and health problems, and correct refractive errors by prescribing eyeglasses and contact lenses. Optometrists in the United States are also licensed to prescribe medications to treat certain eye problems and diseases. The scope of medical care that can be provided by optometrists is determined by state law.


An ophthalmologist is a medical doctor (MD) or an osteopathic doctor (DO) who specializes in eye and vision care. Ophthalmologists are trained to perform eye exams, diagnose and treat disease, prescribe medications and perform eye surgery. They also write prescriptions for eyeglasses and contact lenses. It is important to seek care from an eye doctor highly trained if you already have a medical eye problem such as glaucoma, macular degeneration or cataracts. In many cases, this means that medical or surgical eye care by a specially trained ophthalmologist is in order.

Another factor in the patient’s selection of an eye doctor is determining if he or she is an authorized provider under the vision or medical insurance plan. Most optometrists and ophthalmologists accept Medicare for older patients. However, while Medicare covers your visits to an eye doctor for medically necessary eye care, it does not cover routine eye exams. Prior to the submission of a claim, it’s helpful to verify coverage and out-of-pocket expenses for the exam.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The above is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about.


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Claims Processing: Dental Claims vs. Medical Claims

There are some similarities between preparing dental claims and medical claims. For example, patient and insurance demographics and insurance information that must be provided to medical carriers are similar.

However, there are some very significant differences between the two. While dental carriers typically require a procedure code. Medical carriers not only require procedure code(s) but also the reason why the procedure(s) were performed or the patient’s diagnosis.

Diagnoses are classified in code form in the ICD-9-CM “International Classification of Disease, Ninth Revision – Clinical Modification” manual. Without at least one diagnosis code that supports the procedure(s), the medical claim will not be paid. There must be an appropriate diagnosis to establish the medical necessity of the procedure. This is probably the most important part of successful dental-medical cross coding.

Another very significant difference between dental and medical coding systems is the time period and frequency between updates, deletions and revisions. All medical code sets update yearly and medical carriers generally offer no grace periods on using outdated codes.


The medical claim form also has some major differences compared to the dental claim form. Most medical carriers require the CMS-1500 (08-05) claim form. Medical carriers require these preprinted, red-inked forms because these forms are the only ones that scan correctly. Hand-written claims and comments or copies are not accepted.

Apex EDI can provide the best medical electronic billing for all of your medical claims and dental claims. The main benefit to implementing a dental-medical cross-coding system is satisfied patients who recognize your willingness to help them save their dental plan allowance and access medical benefits. Grateful patients can become your most valuable marketing asset.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The above is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about.

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