What Are Medical Claims?

by Traina Clarke

Medical claims are medical bills submitted to health insurance carriers and other insurance providers for services rendered to patients by providers of care. When you go to the doctor, hospital or other provider, your service generates a bill. This bill then becomes a medical claim to your insurance carrier to process for payment. The term “medical claim” can be easily defined, but understanding all of the required knowledge you must obtain about medical claims to work in the health care industry is all together different.

Medical Claims Terminology

It is helpful to know medical claim terminology when you handle medical claims. Medical claim terminology includes words and phrases such as “date of service,” “procedure code,” “CPT code,” “diagnosis code,” “place of service,” “type of provider,” “modifier,” “participating,” “non-participating,” “usual and customary,” “non-allowable” and more. To learn these words and phrases, it is best to pick up health care information textbook that will explain the basics of what happens to your bill when it goes from the doctor to the insurance carrier.

Medical Claim Providers

Providers submit bills that become medical claims. Any provider you go to for medical care, medical supplies or medical services would have a medical bill that developed into a medical claim for your insurance carrier. There are physicians, nurse practitioners, physician assistants, specialty physicians, skilled nursing homes, hospitals, home health providers, durable medical equipment providers (i.e., wheelchairs, canes, hospital beds), psychiatrists, therapists and mental health counselors, to name a few. Each of these providers of care generally will submit a bill to your health insurance carrier for payment.

Insurance Carriers That Pay Medical Claims

Medical claims are processed by processors at health insurance companies. The types of carriers that process medical claims include federal, state and third parties. Medicare processes claims for beneficiaries that have Medicare for their health insurance. State health programs like medical assistance, adult-only programs and children’s health insurance programs provide health insurance coverage to process claims for those with financial difficulty. Third-party health insurance carriers are carriers such as Blue Cross Blue Shield, Aetna, United Healthcare, Cigna and others. Third-party health insurance carriers are not owned by the government.

Medical Claims Career Tasks

Knowing how to interpret words and phrases, speak the language and who is who in the definition of medical claims is a great start. The responsibilities of a person working in the field of medical claims generally consist of receiving the medical bill, verifying the medical coverage of the member who received care, checking to see if the member has coverage for the particular procedure, supply or service, matching the procedure received by member to a fee schedule or other payment verification system, applying that payment for the procedure based on the schedule or payment system and then sending the payment to the provider of care for services the member received. This process could vary from time to time based on the type of provider of care and insurance carrier.

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About the Author

Traina Clarke writes for the local Examiner in Baltimore. She is the resident expert on health care and health insurance for the online periodical. A lot of the information she writes about is based on her 20 years of health care industry experience in insurance and physician bills.