What Is Claims Processing And How Does It Work?

Claims processing begins when a healthcare service provider has submitted a claim to the insurance company. Sometimes claims are sent directly through medical bills to health facilities and sometimes through clearinghouses.

Basically, claims handling refers to the insurer's process of reviewing claims for proper information, validation, justification, and authenticity. At the end of this process, the insurance company can return all or part of the money to the service provider. 

The company can also deny a claim if it is determined to be invalid, falsified, duplicated, or not in accordance with the terms of the policy. You can also seek help for expert healthcare providers for simplified healthcare claims exchange.

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Insurance companies use a combination of automatic and manual reviews to resolve claims. A payment determination is made where the insurance company decides how much it is willing to pay for the damage.

Explanation of benefits

Once the court decision-making process is complete, the insurance company sends a message to the hospital with the details of the findings and the reasons for the settlement or denial of the claim. This is known as an explanation of benefits or money transfer tips. Under the EOB, healthcare providers can provide more information or request a claim.

Typically, a performance statement contains details such as: amount paid, approved amount, allowed amount, patient responsibility amount, coverage amount, discount amount, etc.

Settlement of claims

This is the final step in which the insurance company establishes the amount to be paid to the service provider for the treatment of the insured patient. This can be done individually for each application created or collectively for all applications received from the same service provider over a certain period of time.