The processing of claims involves several steps, including documentation, submission, review, and resolution.
Documentation Accurate and thorough documentation is the first step in the claims process. This includes recording all relevant patient information, treatments, and outcomes in the medical record.
Submission Once documentation is complete, claims are submitted to the appropriate payer, such as an insurance company or government program. This often involves coding the services provided using standardized medical codes.
Review The submitted claims are then reviewed by the payer to ensure they are accurate and meet all necessary criteria. This review process can involve verifying patient eligibility, service necessity, and coding accuracy.
Resolution After review, the claims are either approved, denied, or returned for additional information. Approved claims result in payment to the healthcare provider, while denied claims may require an appeal process to resolve.
