Top 10 Mastering Medical Claims: Essential Tools for Healthcare Consumers

What Are Medical Claims?

In its simplest form, a medical claim is a request for payment sent by a healthcare provider to the patient's insurance company. This request outlines the services provided to the patient and the corresponding charges. Medical claims contain vital information, including patient demographics, diagnosis codes, procedure codes, and the provider's information.

The Process Unraveled

The journey of a medical claim begins when a patient seeks medical services. Once the services are rendered, the healthcare provider generates a claim based on the treatments provided and submits it to the patient's insurance company for reimbursement. From there, the claim undergoes a series of steps, including:

Verification:
The insurance company verifies the patient's coverage and the validity of the claim.

Adjudication:
The claim is evaluated to determine whether it meets the insurer's guidelines for reimbursement.

Payment or Denial:
If approved, the insurer reimburses the healthcare provider. If denied, the provider and/or patient receive an explanation of benefits (EOB) outlining the reasons for denial.