Submitting Claims
Claim Submission is the process of sending a request for reimbursement to an insurance company for healthcare services rendered to a patient. This process involves multiple steps, including patient registration, coding, claim validation, submission, tracking, and payment posting.
Accurate and timely claim submission is crucial for maintaining steady revenue flow, reducing claim denials, and ensuring healthcare providers get paid correctly.
What is a Medical Claim?
A medical claim is a document submitted to an insurance company containing:
✅ Patient information (Name, DOB, Insurance ID)
✅ Provider details (National Provider Identifier – NPI, Tax ID)
✅ Diagnosis codes (ICD-10)
✅ Procedure codes (CPT, HCPCS)
✅ Service date & location
✅ Charges for each service
Once submitted, the insurance company reviews the claim to approve, deny, or request additional information.
Types of Medical Claims
There are two primary types of claims in medical billing:
A. Paper Claims:
- CMS-1500: Used for physician and outpatient services.
- UB-04: Used for hospital and facility-based claims.
- Sent via mail or fax to insurance companies.
- Slower processing time with a higher risk of errors.
B. Electronic Claims (eClaims)
- Submitted digitally via Electronic Data Interchange (EDI).
- Faster, more accurate, HIPAA-compliant.
- Can be sent directly to payers or via clearinghouses.
✅ Most insurers now prefer or mandate electronic claims.
The Medical Claim Submission Process
Medical claims go through several stages before reimbursement is approved. Below is a step-by-step guide to the claim submission process.
Patient Registration & Insurance Verification
- Collect accurate patient demographics (Full name, DOB, address, contact).
- Verify insurance eligibility via online portals, phone calls, or clearinghouses.
- Confirm co-pays, deductibles, coinsurance, coverage limits.
- Check for pre-authorization requirements for specific procedures.
- Ensure the patient has a valid referral (if required).
💡 Example: A patient comes in for a knee MRI. The front desk verifies their insurance and finds that prior authorization is needed. Without it, the claim could be denied.
Coding & Documentation
Medical coding translates a provider’s services into standardized codes for billing.
- ICD-10 (Diagnosis Codes): Identifies the reason for treatment.
- CPT (Current Procedural Terminology): Describes medical procedures performed.
- HCPCS (Healthcare Common Procedure Coding System): Used for supplies, medications, and non-physician services.
- Modifiers: Provide additional details about the procedure (e.g., laterality).
Example:
- A patient is diagnosed with a sprained right ankle.
- ICD-10 Code: S93.401A (Sprain of unspecified ligament of right ankle).
- CPT Code: 73610 (X-ray of ankle, 3 views).
- Modifier: RT (Right side).
Accurate coding prevents claim denials due to coding mismatches.
Claim Creation & Validation
- Enter patient, provider, and service details into the billing software.
- Verify that all required fields are filled out.
- Check for common errors, such as missing provider NPI or incorrect diagnosis codes.
- Run a scrubber tool to detect and fix coding or format issues.
💡 Best Practice: Many billing systems have real-time claim validation that flags errors before submission.
Claim Submission
Monitor the claim using insurance payer portals or billing software.
Common claim statuses:
- Accepted – The claim is being processed.
- Pending – The insurer is reviewing the claim.
- Denied – The claim is rejected due to errors or lack of information.
- Paid – The claim is approved, and payment has been issued.
💡 Example: If a claim is denied for missing information, resubmit it with the required details within the allowed timely filing limit.
Why Choose Us?
✅ Faster Payments – We reduce claim rejections and accelerate reimbursement cycles.
✅ Reduced Administrative Burden – Your staff can focus on patient care while we handle billing complexities.
✅ Compliance & Accuracy – We stay ahead of industry changes, keeping your practice compliant and profitable.
✅ Custom Solutions – Whether you’re a small practice or a large healthcare organization, we tailor our services to your needs.