Billing Claim Medical Software Process
Processing claims via Paper or Medical Health Insurance Claim Software

Billing claim medical software Learn what’s involved with creating and processing electronic and paper CMS 1500 claims. We'll describe in detail the process an insurance claim goes through.

Insurance Claim Process
The claim process starts when a claim is received either via mail or electronically by the insurance payer. Paper claims are on the standard CMS-1500 insurance form (UB-04 for hospitals). When received by mail any attachments are removed and the paper claim is scanned into electronic format.

Electronic claims are created by the billing claim medical software in a format acceptable to the insurance company. Most billing services and practices use a clearinghouse to scrub electronic claims and put the electronic claims created by the clients billing claim medical software in a standard format for transmission.

Here's a flow chart in PDF format that shows the claim process in simplified form for healthcare claim processing described below.

  1. The electronic claim is received - either from paper scan or electronic transmittal. The insurance processing computer(s) identify the patient and policy information. If the names or policy information does not match the insurers data base, the claim is rejected.
  2. Medical necessity is established by comparing the procedure codes to the diagnosis codes. If determined to be not medically necessary, the charges are not allowed.
  3. The procedure codes and dates of service of the claim are then scrutinized. This is to make sure the codes are allow by the policy and checks for any pre-authorized restrictions. If not authorized the procedure is determined to be unauthorized or uncovered and the claim is rejected.
  4. The amount allowed for a procedure is then determined. Any amount beyond the maximum allowable amount is considered to be a provider write-off. The maximum allowed charges per procedure varies depending on the patient policy.
  5. The amount the patient is responsible for per policy annual deductible, coinsurance, and copayment obligations is determined.
  6. The Explanation of Benefits (EOB) statement is generated. The EOB is provided to the patient and to provider with insurance payment. The EOB shows:
  • Dates of service
  • Procedures and charges
  • Patient responsibility in the form of coinsurance, deductible, copays, or non covered charges
  • Provider write-off amountAmount paid to provider

Claims Created by Billing Claim Medical Software
Creating an electronic medical billing claims typically involves the creation of an electronic file using the practice or billing service billing claim medical software. These claim files can contain information on several patients depending when the last claim file was generated. I typically perform this on a daily bases for our practices.

This file is usually in a standard electronic format such as a print image or ANSI format. The file is uploaded to the clearinghouse for processing – usually through their website. The clearinghouse translates the claim information into the appropriate electronic format and sends it to the various insurance carriers. HIPAA legislation established Electronic Data Interchange (EDI) standards for transmission of healthcare claims data.

The clearinghouse will typically check the claims for errors soon after submittal and provide a report letting you know if any of the claims were rejected and why. A few days later another report is provided through the clearinghouse from the insurance company indicating the claims were received and if there are any rejections. This is a tremendous help in getting the claims correct up front.

If there are errors or rejections, the claim must be corrected in the billing claim medical software and resubmitted. Errors are usually typos in the insurance ID number or procedure/diagnosis codes. Other common mistakes are the omission of claim data.

Always make sure you receive a confirmation report from the insurance carrier(s) through the clearinghouse and review it carefully. The clearinghouse we use will post these reports on their web portal.

Check Your Clearinghouse Reports Regularly
One of my providers had a lot of Medicare claims that were being accepted by the clearinghouse, but we never got confirmation reports from Medicare. After investigating we found out that our Medicare reports were being sent to another account.

But the worst part is that Medicare had been rejecting our claims for over a month and we never knew it. We were creating and resubmitting claims in the billing claim medical software over and over with no feedback that the claims were being rejected - what a wasted effort! Since our provider only sent us EOB's every few weeks, we didn't know claims were getting rejected for weeks. We found out our clearinghouse was putting the legacy UPIN provider number in the claims. This was after Medicare would only accept claims with NPI.

Good Clearinghouse Technical Support is Important
When beginning service with a clearinghouse, you have to work out the formatting of the billing claim medical software file so the clearinghouse can accept it. It's very important the clearinghouse have good technical support so you can get set up quickly. Our clearinghouse was very helpful in telling us how to set up our medical claims billing software.

Our clearinghouse tech support will actually log onto my workstation to help during setup or when we are having problems and make the necessary changes in our billing claim medical software. This is a tremendous help as I am not an IT expert - nor do I want to be. My approach is to concentrate on the medical and find an expert to deal with all the other IT stuff.

Paper Medical Billing Claims (or CMS 1500)
If a practice does not have the capability to send an electronic claim, the insurance billing specialist will need to send paper claims, these are on a paper form called a CMS 1500.

There are also some smaller insurance carriers are not able to accept electronic claims. Even for those practices sending primary claims electronically, secondary and tertiary claims are usually submitted on paper. These types of claims require attaching the primary EOB.

Most billing claim medical software already has the CMS 1500 form format. You just use the pink blank CMS 1500 forms when printing - these are the forms with the red lines and boxes pre-printed. This involves printing statements out from the practice management software.

Once printed out the CMS-1500 forms are then mailed to the insurance payer.

Fill and Print Software for Medical Billing Claims
There is also inexpensive File and Print software available which allows you to enter and print directly on the CMS 1500 forms. The better ones have the capability to store insurance, provider, and patient information as well as the CPT and ICD-9 medical billing codes. This can save a lot of effort for a medical billing specialist - especially compared to filling out by hand. I highly recommend Speedy Claims. It’s only about $115.

Billing for facilities such as hospitals or outpatient facilities is submitted on form UB04. These forms have different fields than the CMS 1500 and can be tricky to fill out. Some providers can actually bill as either as a facility (UB04) or a professional (CMS 1500) depending on how they are credentialed.

Electronic Claim Processing Best
In summary health insurance claims sent electronically are typically processed much faster than paper claims. The electronic claims created via billing claim medical software are typically processed with two weeks for most of our clients. Paper claims will take up to four weeks or longer depending on the insurance carrier. Electronic claims are also less costly to process (no postage) and are less likely to be rejected or unpaid due to the “scrubbing” performed by the clearinghouse.

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