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MEDICAL BILLING Claims Submission Process
First, the claims processing or billing service acquires the needed information from the medical practice (a Superbill). This data is then entered into computer software. Most software contains editing capabilities and can detect a number of errors at this time. When a batch of claims have been entered, and they are determined to be error-free, the operator transmits them.
Transmission is accomplished with the use of computer modems, communications software and telephone lines. Claims can be transmitted in two different ways. They can be sent directly to the carrier, if the correct software is being used, or they can be routed through a clearinghouse. If a clearinghouse is used, it re-edits the information, formats it and sends it on to the carrier. The carrier makes the final decision on payment of the claim and the medical practice usually receives payment within 14-18 days.
With paper claims, it usually takes the medical practice 30 to 90 days or even longer to receive payment from insurance carriers. Claims filed electronically, however, are generally paid much more quickly.
If an electronic claims processor uses a clearinghouse, the clearinghouse will take most claims that cannot be sent electronically and "drop them to paper," mailing them for a minimal charge. Even though some claims have to go by paper, a medical office is still better off with a billing center that uses the services of a medical insurance clearinghouse. Extensive editing provided by the clearinghouse assures "clean claims." Most clearinghouses boast a 98-percent accuracy rate. One even claims to have an accuracy rate of 99.3 percent. You can assure a medical office you serve that none of its claims will be forward to a carrier with a simple omission that might cause the carrier to suspend or reject the claim. An electronic claims processing center can realistically tell a medical practice that their claims will be paid in 14 to 18 days on average, and that the accuracy rate will be 98 percent or higher.
The Insurance company forwards a check to Doctor along with detail statement of what was paid (Explanation of Benefits- EOB).
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