Home / Health / What Are The 5 Steps in Medical Claims Process?

What Are The 5 Steps in Medical Claims Process?


Medical billing is pretty complicated, and also time consuming. However, when you outsource medical billing services to agencies with trained professionals, proper systems and modern technology, you can rest assured that your medical billing will be carried out in a smooth and seamless manner. This because third-party vendors have a well-defined process to file and claim bills. These agencies follow the 5 basic steps to make their medical claims process more precise.

1. Patient Check-in


This is the step wherein a patient’s demographic information – name, age, gender, address, medical history – insurance provider, and policy details are registered. The process needs to be carried out with great accuracy because any wrong information can lead to delay in claims.

2. Insurance Eligibility and Verification


It’s mandatory to verify insurance details and eligibility of every patient before appointment, to ensure the patient stands covered for the treatment. Yet another reason is to ascertain changes in insurance information. Improper verification can affect the benefits available and impact the authorization process, so it is critical that it is checked accurately at the very first instance.

3. Medical Coding Process


It is crucial that all diagnoses, procedures, and services are assigned the correct codes by the medical coding services professionals. This helps the insurance company to know precise details about the patient’s illness or injury and the treatment they are receiving. This includes using accurate code modifiers so that details about the services and procedures can be ascertained.

4. Claims Submission


After coding, the bill is complete and ready to be submitted to the insurance payer for settlement. Medical billing teams need access to information on the insurance company, as the procedures and methods of claims submission can vary from payer to payer. Though there is a generic set of instructions for billing and claim submission, some insurers have separate guidelines; at least for a few aspects of billing. As a medical biller, it is to check with the payer that the correct procedure is followed while submitting claims.

5. Payment Posting

If the insurance payer has paid the amount in full, the patient’s bill will be zero; else, payment posting needs to be done to reflect the amount the patient needs to pay. In case the insurance provider doesn’t pay the full claim or rejects the claim, the billing team follows up with the patient to ensure payments are collected on time.

When you outsource medical billing services to a specialized healthcare BPO company, you get each of these steps done in a highly streamlined manner. This frees you to focus on your core competencies – patient care. As a result, you can achieve more efficiency and enjoy better revenue management too.