August 03, 2020


The visit has produced a bill which is about to become a claim. This presents more opportunities for payment prospects to decline if the contract with the insurer is misunderstood or the wrong information is entered. Outside medical claims advice may be needed at this point or you my be able to figure out what went wrong on your own. Review this flow chart, the outline and the more in-depth sections. If you already have a denial, try to isolate the stage that it happened and what misinformation may have been entered. Then, when you talk to customer service and are able to speak knowledgeably about what they did wrong - in effect, lead them by the hand - the chances of your claim then being paid increase exponentially.
Life of a Claim (Part 2):


Claim Submission (One of the most annoying things that happens here is the insurer never receives the claim. At least that's what they say when you call for claim status a few weeks later when it's still not paid)
1. Billing Policy Determined - The practice staff implements the billing policy and methodology before seeking any medical insurance claims remittance.
2. Claim sent - This is mainly done electronically to a patient’s health plan. Billing for medical care the physician has provided, it generally includes the physician’s retail charge for those services.
Claim Adjudication  (The insurer's claims payment software is supposed to be accurate even foolproof, but plenty - maybe even the majority - of errors are inexplicably applied to the claim right at this stage)
3. Claim received in administrative system - The health insurer receives the claim directly from the provider, through a billing service or from the patient.
4. Patient’s eligibility and benefit level determined - The health insurer determines the patient’s covered and non-covered services and procedures based on the enrollee’s health benefit plan.  
5, Claim pricing edits applied - The health insurer applies pricing edits, which reduce the physician’s billed charges to their individually contracted maximum allowed payment.

6. Health insurer proprietary claim edits applied - The health insurer’s administrative system makes adjustments the claim through its own specific proprietary edits and determines whether the specific codes are eligible for payment.

7. Adjudication completed - The health insurer determines the final payment and queues the “to be paid” amount and details into its system.
Claim Payment  (The last place to mispay the claim - drop a zero, for instance - or lose the payment in the mail altogether. Maybe these lost payments are in the same dimension of the universe as lost socks after doing  the laundry, because there sure are a lot of them!)
8. EOB/RA generated - The health insurer sends an EOB/RA to the physician and patient, detailing the paid amount of the medical service provided.

9. Payment sent - The health insurer mails a check or submits an electronic funds transfer (EFT) to the provider's bank. The health insurer typically sends the manual payments along with the EOB/RA. If it's not correct, further medical insurance claims advice may be needed.
Related Resources:

Medical insurance claims advice from a lawyer who knows. He highlights the biggest mistakes that health insurance policy holders make: 1. insurer will try to rescind the policy for misstatements made on the application, 2. insurer will try to get out of paying by saying that the condition that you're claiming for is pre-existing, 3. what the policy actually will cover and not cover, 4. memorialize in a notebook all conversations that they have with the insurer for later when the insurer tries the he said/she said tactic, and 5. medical record requirements and guidelines.