A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment.
As a medical biller, to ensure that the doctor (known as the provider) gets paid for the services, you must submit every claim as it is directed by the insurance payers contract. It is important to note that every insurance payer will have slightly different rules, depending upon their policies and process.
As a medical biller, you will encounter many billing and coding peculiarities unique to each insurance payer. This is also why many doctors offices choose to use a Medical Billing company (often know as a clearinghouse) to do the submissions, as they have a lot of experience working with each individual payer.
If you are managing the Medical Billing in your office, the best way to find out about these rules and payer-specific peculiarities is to read through the insurance contracts or call the payer relations line to ask questions and understand their submission requirements.
Once an insurance payer receives the claim from you, the company then reviews the claim to determine the following:
1) Whether medical necessity has been met in this patient’s case.
2) Whether the insurance claim is covered by this patient’s plan.
3) What the reimbursement allowance is for this specific patient case.
To determine this, the payer references the contract that is in place with the service provider.
It is also important to know that many insurance companies today have claim submission portals on their websites. These forms allow doctors offices to submit claims directly.
However, because the process can be time-consuming (due to having individual websites for each carrier), this system isn’t efficient for larger doctors offices, and is another key reason doctors choose to use medical billing companies.