Processing Medical Insurance Claims Because the cost of medical expenses is getting more and more expensive each year, people are depending on health insurance to help them pay partially the cost of the medical expenses, which are helpful in their financial and health conditions, and which prompts them to subscribe in health insurance because of the affordable terms, which is paying the premiums in either monthly or annually. When a health insurance subscriber wants to make use of her insurance benefits for medical treatment, hereby are the procedures which she will have to observe: the subscriber hands over her insurance card and fills out a demographic form at the healthcare provider’s office or clinic, and the demographic form requires the following data: patient’s name, date of birth, address, Social Security number or driver’s license number, the name of the policyholder, and any additional information about the policyholder, if the policyholder is someone other than the subscriber/patient; also, the subscriber or patient presents a government-issued photo ID. After completing the paperwork, she proceeds for consultation and treatment on her health concerns with the healthcare service provider or otherwise referred to as the physician, which after a series of consultations, treatments, and tests, all chargeable costs are going to be documented by a medical biller and coder of the healthcare service provider, to which this document is called the medical bill or the medical insurance claim.
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The medical biller enters the information into the appropriate claim form through a billing software, in which the claim is sent to the payer, which is the health insurance company, and to a clearinghouse, which is a third-party company whose function is to check any errors documented in the claim.
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When the health insurance company receives the medical claims, if there is no clearinghouse doing the validation, there are three possibilities that the health insurance company can act on the medical claim: accept all expenditures and pay the bill or deny the claim on account of a billing error, to which the bill is returned to the healthcare provider to be corrected or reject the claim on account that the services rendered are not covered within the health plan of the patient. This just shows the value of a clearinghouse, where errors are immediately addressed including which services are covered under the health insurance, such that the healthcare provider will be sending over a corrected medical claim to the health insurance company and in this process, there is a likely possibility that the previous options, such as denying the claim due to an error and rejection of the claim on account that the services are not covered by the health plan, may be eliminated.