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Medical Claims: What Are They and What Do They Entail?

what are medical claims?

A medical claim is a medical billing statement made by a doctor or other medical professional specifying specific actions expected from using a particular medical treatment. Medical claims indicate the expenses that a patient incurs during the treatment process and are filled by doctors who forward them to the patient’s health insurance provider. The main goal of the medical claim is to reimburse patients for the expenses they incur during the treatment process.

These claims are legally binding. As a result, having a deep understanding of what they entail and the filing process is essential.

Verification for medical insurance eligibility

This is a process where doctors or insurance companies verify that the patient meets all of the necessary criteria to be covered by the insurance. It involves analyzing the types of benefits the patient enjoys under a particular insurance cover. The company also verifies that a licensed doctor performed the treatment or medical intervention.

This process can take some time, so it’s essential to begin as early as possible.

How do medical claims work?

The medical billing process typically starts with the doctor, who is responsible for changing patient information to codes through medical coding process. These are sets of specific numbers that identify specific types of medical claims. The standard coding techniques are:

• National Drug Code
• Current Procedural Terminology
• International Classification of Diseases

The doctor adds this information to the patient’s medical claim form and sends it to the insurance company, which will review the claim and either approve or deny it. Usually, these companies send invoices to successful medical claim applicants. However, the insurance companies provide a written explanation if it rejects the claim.

What do the medical claims entail?

Medical claims files include information particular to each patient. The file has two sections; the claim header and the claim detail.

Claim header

A claim header is a section where doctors include summary information about the patient and the services provided. It consists of a patient’s name, date of birth, gender and date of admission. Additionally, a patient’s National Provider Identifier is mandatory in this section for successful reimbursement.

Moreover, this section mentions the patient’s specific health insurance provider in addition to the name and contact details of the medical practitioner attending to the patient.

Claim detail

Claim detail will include information about the treatment(s), the date and time of service, and other critical information. The section also gives an in-depth description of any complications that may arise during the treatment process.

The goal of making a medical claim is to ensure the proper compensation of a patient by an insurance company. As a result, this section also contains information about the cost of the treatment.

What are some common benefits of using medical claims?

Medical claims help to ensure accurate billing. For example, medical practitioners may want to consider making medical claims so that their patients can be certain that the doctors are using their money for the intended purpose. The claims also help patients save money as insurance companies usually cover the treatment cost in other cases.


Check out related articles surrounding How to Make Sure Your Insurance Claim Gets Paid and Understanding the Medical Billing Process as a Patient.

For more on Medical Billing & Coding, Healthcare Administration, and Insurance News and Updates, you’re already at the right place. Be sure to stay on top of everything by subscribing to the Rx for Success Medical Billing Blog here!

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