Unraveling the Mysterious World of Medical Claims

A medical claim, a truly valuable source of information for a provider or health care organization. The claim contains diagnosis details, information on procedures performed, and patient demographic information. A claim is submitted by the provider to the patient’s health insurance. It will contain medical codes to spell out what care was given during the visit. These codes describe the diagnosis, procedure, supplies used, devices, pharmaceuticals used, and any medical transportation used.

A medical claim will have a header, which would summarize the essence of the claim. This information is inclusive of patient information, like the date of birth, gender, and address. Other details would include the physician or facility National Provider Identifier (NPI), a primary diagnosis code, diagnosis-related group, name of the insurer, and overall charge amount for the claim. After those items, you’ll see information for the secondary diagnosis and procedures performed during a hospital stay or visit with a medical practitioner. The details lay out the date service was administered, code for procedures, diagnosis code, the National Drug Code if medication was administered, the doctor or medical professional’s NPI code, and charge information for the services rendered.

Once the process of preparing the claim is done it is submitted to the insurer for adjudication. The payer receives the claim and evaluates to see how much will be paid, denies or approves the claim and then there’s the approval or rejection of the claim. What comes next is either waiting for the submission of reimbursement or resubmission of a corrected claim. If you want to avoid the process of waiting for payment in a loop of resubmissions the team at Gables Medical Billing is ready to submit your claims and follow them through to reimbursement without having to do the cleaning and resubmission in-house. Leaving your team to help customers and ensure that your practice has optimal customer service standards and is putting the patient and their needs first.