In recording a patients name when sending it to a payer, what version of their name should be used?
Medical claims are some of the most valuable sources of data for healthcare organizations. All-payor claims contain detailed diagnosis and procedure information for any billable patient visit. Healthcare organizations can use this claims information to: Show
It can be difficult to do all this without fully understanding medical claims data. In this blog, we’ll help you learn the basics about medical claims: what they are, where they come from and what they mean. What is a medical claim?A medical claim is a bill that healthcare providers submit to a patient’s insurance provider. This bill contains unique medical codes detailing the care administered during a patient visit. The medical codes describe any service that a provider used to render care, including:
When a provider submits a claim, they include all relevant medical codes and the charges for that visit. Insurance providers, or payors, assess the medical codes to determine how they will reimburse a provider for their services. In a value-based care model, length of stay and 30-day readmissions impact provider reimbursements. What information does a medical claims file contain?Every medical claims file contains details specific to each patient and patient encounter. In a medical claims file, this information is split in two parts: the claim header and the claim detail. Claim headerThe claim header summarizes the most essential information in the claim. This includes confidential patient information like date of birth, gender and zip code. The claim header also contains details like:
Claim detailThe claim detail includes information about secondary diagnoses or procedures administered during an inpatient hospital stay. Each new claim detail, or service record, contains the following information:
What is a medical claims clearinghouse?A medical claims clearinghouse is an electronic intermediary between healthcare providers and payors. Healthcare providers transmit their medical claims to a clearinghouse. Clearinghouses then scrub, standardize and screen medical claims before sending them to the payor. This process helps mitigate errors in medical coding and reduces the time to receive provider reimbursement. If a claim contains medical coding errors or fails to meet formatting requirements, the payor could reject it. This means that the claim would be resubmitted, delaying provider reimbursement. The service that clearinghouses provide is also beneficial for payors. Clearinghouses format medical claims data according to the unique requirements of each payer. Standardizing the data in this way helps payors streamline their medical billing process. What is the medical billing process?The medical billing process contains seven essential steps. These steps trace the entire claims journey from the moment a patient checks in at a healthcare facility, to the moment they receive a bill from their insurance provider. Fig. 1 Illustration of the medical billing process. Circle diagram displays the seven-step process that a medical claim goes through. Illustration from The Definitive Approach to Healthcare Sales – 101: Codifying the Patient Journey. Patient registrationPatient registration is the very first step in the medical billing process. Registration occurs when a patient gives their provider personal details and insurance information. Insurance eligibility verificationAfter a patient has registered, the care provider must verify the patient’s insurance. This helps to confirm that the patient has adequate coverage for the care that they will receive. Verification helps care providers determine coverage and eligibility, and assess the following:
Medical codingMedical coding is a critical step that occurs after care has been administered. Care providers transcribe their notes and other clinical documentation into standardized medical codes. Some of the most common medical coding systems include:
Care providers use these codes to describe which medical diagnoses, procedures, prescriptions and supplies they administered and why. The specificity of medical codes also helps providers describe the patient’s condition. Charge entryCharge entry is the last step before care providers submit their claim for payment. Providers or medical billing specialists list the charges that they expect to receive. Claims transmissionClaims transmission is when claims are transferred from the care provider to the payor. In most cases, claims are first transmitted to a clearinghouse. The clearinghouse reviews and reformats medical claims before sending them to the payor. In some cases, healthcare providers send medical claims directly to a payor. High-volume payors like Medicare or Medicaid may receive bills directly from providers. This helps to reduce the time that it takes to receive reimbursement. AdjudicationAdjudication occurs once the payor has received a medical claim. The payor evaluates the claim, then decides whether the medical claim is valid and how much of the claim they will reimburse. If the claim is accepted, the payor will issue provider reimbursement and charge the patient for any remaining amount. The payor may deny the claim if the patient has insufficient coverage or did not get pre-authorization for a service. If a payor denies a medical claim, the patient may have to submit an appeal to gain coverage for the care costs. The payor may also reject a claim. This happens when the claim does not meet formatting requirements or contains an error in medical coding. Rejected medical claims can be resubmitted for payment once the errors have been corrected. Patient statementPatient statement is the final step in the medical billing process. Once the payor has reviewed a medical claim and agreed to pay a certain amount, they bill the patient for any remaining costs. Learn moreAre you interested in learning more about medical claims data and how to use it? Catch an on-demand replay of our webinar: The Definitive Approach to Healthcare Sales – 101: Codifying the Patient Journey. If you’re ready to get hands-on access to medical claims data, provider profiles and powerful analytics, schedule a free trial with our healthcare commercial intelligence platform. What is the first step in posting a payment to a patient's account?The first step, collect patient and insurance info. Our Benefits Authorization process gets medical services authorized (pre-authorization or prior authorization) from the insurance payers. Without an authorization, the insurance payer is free to refuse the payment.
What are the terms used in medical billing?Glossary of Billing and Insurance Terms. A. Account number. The number assigned by your provider (hospital, physician, home care service, etc.) ... . B. Beneficiary eligibility verification. ... . C. Certification number. ... . D. Date of bill. ... . E. Effective date. ... . F. Federal tax ID number. ... . G. Generic drug. ... . H. Healthcare common procedure coding (HCPC). What type of signature should be used in item number 31?Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha- numeric date (e.g., January 1, 1998) the form was signed.
What is the name of the currently accepted universal claim form for the medical office?The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of ...
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