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Processing Medical Insurance Claims

Due to the cost of medical expenses, most people make practical investments by entering into an arrangement with a health insurance company in order to reduce the impact of medical expenses, such that they are required to pay premiums, which are known as subscription fees, which are scheduled to be paid monthly or annually.

When the health insurance subscriber wants to avail of her health insurance for the purpose of seeking medical treatment, she has to hand over her insurance card and fill up a demographic form to enter data requirements, which will be needed later on for processing medical insurance claims, and these are: 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.

Once the paperwork is completed, the patient proceeds for consultation and treatment to a designated physician, such that whatever else are serviced to the patient will all be reflected as chargeable costs which will be recorded by a medical biller and coder of the healthcare service provider, to which this recorded document will serve as the bill or medical insurance claim.
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As soon as the coder hands over the bill of the patient to the medical biller, the information on the bill is entered as information by the medical biller into an appropriate claim form through a software billing application, in which the claim is sent to the health insurance company of the patient and to a clearinghouse, which is a third-party company that operates on checking and validating the document from errors found in the claim.
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Without a clearinghouse, the health insurance company of the patient may possibly act on these possibilities, as soon as it receives 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. 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.