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Processing Medical Insurance Claims Since the cost of medical expenses are getting to be expensive, it will be difficult to be sick and hospitalized, especially if you don’t have much financial resources, and that’s why most people are into health insurance in order to reduce the impact of medical expenses, and since payment coverage of health insurance is affordable since you pay premiums either on a monthly or annual basis, more and more are subscribing in it. If the time comes when the health insurance subscriber is in need of using her health insurance benefits for medical treatment, the first thing to do is for her to go to the healthcare provider’s office or clinic and hand over her insurance card and in exchange, she receives a demographic form for her to fill up with required data, such as: 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, and a government-issued photo ID. After finishing the paperwork, the patient now sees a designated physician who will provide the consultation and treatment service, as well as other medical procedures that are needed to treat the patient, after which all these services are going to be recorded by the coder and determine the charge cost of each service by the medical biller, such that the summary of these charges is called the medical bill or also referred to as the medical insurance claim.
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Once the coded bill summary is handed to the medical biller, he/she enters all information into an appropriate claim form using a software billing application, which will further be sent to the payer, which is the health insurance company of the patient, and to a clearinghouse, a third-party company, which operates by validating medical claims to check on errors in the document claim.
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If no clearinghouse is hired to validate the claims, when the health insurance company receives the medical insurance claim, there are three possible actions that may occur: 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. Therefore, this indicates the importance of a clearinghouse of which the original bill can be reformatted to include corrections which were validated by the clearinghouse firm and once the new medical claim is presented to the health insurance company, there is a good chance that 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.