Healthcare Claim Processing: What You Should Know

healthcare claim processing

The healthcare industry is constantly in flux, with its various components coordinating with one another to deliver patient care. They also need to work together seamlessly to ensure that the medical facility gains the payment for the delivered care without a hitch. The high costs of all things medical make out-of-pocket expenses a rarity, meaning the facility will be dealing with many insurance claims relentlessly.

There is a lot to unpack about this aspect of the healthcare industry since it involves the detailed recording of treatments, diagnoses, and care provided. It also includes compliance with many regulations and standards that keep getting updated regularly. Additionally, such high volumes of claims across multiple insurance providers can be a hassle to handle accurately. A single healthcare facility’s staff can get overwhelmed trying to complete all related tasks, leading to errors, delays, wrongful sums getting paid, and fraudulent behaviors. Outsourcing healthcare claim processing can ease such woes, providing your facility and its patients with the mental comfort required.

Continue reading to learn about the various aspects of healthcare claim processing and the advantages outsourcing brings to your business.

What is Healthcare Claim Processing?

Most healthcare bill payments happen through insurance policies taken by patients. Healthcare claims processing is how medical facilities send bills to insurers to compensate them for the treatment they provide to patients.

Unlike other industries where billing is a straightforward task of noting down everything in a list and attaching associated rates to them, medical billing goes through a series of complex steps. The need to stay in line with all applicable regulations and standards at every step and work within the terms laid out by insurance companies about how forms should be filled makes it a challenging undertaking.

Healthcare claim processing is even more complex because the insurer covers only part of the bill. Costs of some services and medications have to be borne by the patient as a co-pay.

When Does Claim Processing Begin?

Healthcare claim processing procedure begins when a patient checks into a medical facility for treatment. It continues for the duration that the person is under the care of the medical treatment providers and ends only when a patient pays the final bill.

What Is an Insurance Network?

Insurance companies create a list of healthcare facilities by signing contracts with them that brings those facilities under their network. It means that a patient subscribed to an insurance plan covered by that provider will have their bills covered if treated in any of those healthcare facilities. The claims made in such facilities get automatically processed as the healthcare provider submits the claim.

Patients can also get insurance companies to pay for treatments outside the company’s network by submitting claims themselves. This depends on the clauses laid out by the insurer for the plan opted for by the patient. The major difference is that when the healthcare facility submits claims, it does so through professionals who are aware of regulations like HIPAA and ensure that the sensitive personal information contained in the documents remains confidential.

The Steps Involved in Healthcare Claim Processing

Since the tasks involved with claims processing are elaborate and require scrutiny, healthcare facilities tend to have dedicated departments with qualified personnel managing the work. In other cases, the facility may outsource healthcare claim processing to ease the burden of the tasks and maintain accurate, on-time processing.

If the claim being processed is by an in-network facility, then the following steps occur:

  • Once the patient is admitted to the hospital and the required treatments are provided, the insurance provider gets sent a bill containing the charges for every service rendered. This doesn’t contain the charges that the patient may have already paid upon checking in as a part of the co-pay.
  • The claim undergoes review. It is checked to see if all the information in the claim forms is accurate. They then compare that against the insurance plan to verify if the services rendered by the facility are covered under the plan.
  • If the claim contains services covered under the plan opted for by the patient, then the insurance agency will pay that claim. They may pay the total amount based on the plan or a part of it. In the latter case, the remainder of the bill has to be covered by the patient.
  • The totaled amounts for the deductible and out-of-pocket portions will be validated as per the policy opted for, and the respective details will be updated immediately.
  • A document containing the explanation of benefits is sent out that details what services were rendered, how many of those were covered by the insurance, how much was paid by the provider, and the services remaining to be billed.
  • The patient then receives the final bill for payment. It falls upon the patient to verify if all the information in the bill is accurate. Sometimes, errors make their way into such bills via wrongful coding or clerical input. In such circumstances, the patient can refuse the bill and send it for reevaluation. This happens without any extra charges to the patient.

Filing a Claim When Outside of the Network

If a patient gets treated by a healthcare provider outside of the insurance network of the patient’s plan, then the patient has to file the claim themselves, provided that their pal covers such expenses. The patient may fill in the details or have an external healthcare claim processing service do it for them.

In this case, the steps to process the claim are as follows:

  • The patient fills out the claim form aligned with their benefit plan. Relevant details can be found on the insurance provider’s website by logging into it using the patient’s credentials.
  • This form filling happens online to avoid the ambiguity of handwritten information. However, there is a provision to have the forms printed and filled by hand. Here, the filler should ensure that the written content is legible and unambiguous.
  • The plan is validated against the services provided to check which ones are covered under it and which ones lie outside its purview. Claims must be made for those under coverage; otherwise, the claim will get denied.
  • All medical codes and relevant information provided by the healthcare facility, like duration of stay at the facility, should be duly mentioned.
  • The forms are then sent to the insurance company within the due date.
  • At times, a signed pre-approval form may also need to be submitted along with the claim submission. Patients have to verify the same and do it accordingly.

Why a Claim Gets Denied

Denials are the bane of healthcare claim processing. It hurts the patient to expect the claim process to go smoothly and may be unable to wait for resubmission to go through after verifying details in the claim form. Claim denials harm the healthcare service provider by delaying payment of dues and disrupting their medical and administrative functioning.

They also harm insurance providers as the insurer has to expend unnecessary resources to reprocess claims, sometimes repeatedly. Thus, it’s in the best interests of everyone involved to know why and how claims can get denied to prevent unwanted issues. Using a dedicated claim processing services agency helps in this case as they ensure the accuracy and timely submission of claims, thereby reducing the chances of denials.

Below are some of the reasons that a claim may be denied that one should be aware of:

  • Using the wrong forms
  • Sending forms with incorrect information filled
  • Patients receiving treatment without pre-authorization
  • Filing claims past the due date
  • Service not covered by the insurance plan
  • The services rendered are deemed unnecessary by the insurer

Patients can ask for denials to be overturned by calling the biller and discussing the details behind the denial. If the reason for the denial is one of the above, then an attempt can be made to have it resolved over a phone call itself.

If not, the claim may be submitted to the insurer for review. The insurance company will go through the information presented again and decide whether to cancel the denial or ask for resubmission of the claim with the necessary changes to the information contained.


Healthcare is an inevitable requirement for everyone, and claims processing procedures are just as critical to healthcare firms. It saves everyone involved many unwanted hassles, aiding the seamless payment of medical bills. Using a claims processing services provider for the task is a sure-shot way to reduce the risk of denials and keep the overall healthcare system functioning glitch-free.

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Brown Walsh is a content analyst, currently associated with SunTec India- a leading multi-process IT outsourcing company. Over a ten-year-long career, Walsh has contributed to the success of startups, SMEs, and enterprises by creating informative and rich content around data-specific topics, like data annotation, medical claim processing, and email data mining services. Walsh also likes keeping up with the latest advancements and market trends and sharing the same with his readers.