Chapter 7: Health Care Claim Preparation and Transmission

Overview

This chapter provides an overview of the process of preparing and transmitting health care claims. It covers the following topics:

• The different types of health care claims
• The information that must be included on a health care claim
• The different methods of transmitting health care claims
• The importance of timely and accurate claim submission

Types of Health Care Claims

There are two main types of health care claims: institutional claims and professional claims.

Institutional Claims

Institutional claims are submitted by hospitals, nursing homes, and other healthcare facilities for services provided to patients. These claims typically include the following information:

• The patient’s name, address, and date of birth
• The provider’s name, address, and tax ID number
• The dates of service
• The type of service provided
• The amount charged for the service

Professional Claims

Professional claims are submitted by doctors, dentists, and other healthcare professionals for services provided to patients. These claims typically include the following information:

• The patient’s name, address, and date of birth
• The provider’s name, address, and tax ID number
• The dates of service
• The type of service provided
• The amount charged for the service
• The diagnosis code for the service

Information Required on a Health Care Claim

In addition to the basic information required for all health care claims, there are a number of other pieces of information that may be required, depending on the type of claim and the payer. This information may include:

• The patient’s insurance policy number
• The patient’s copayment or deductible amount
• The prior authorization number for the service
• The referral number for the service
• The medical record number for the service

Methods of Transmitting Health Care Claims

There are a number of different methods for transmitting health care claims, including:

• Mail
• Electronic data interchange (EDI)
• Web-based portals
• Clearinghouses

Mail

Mail is the most traditional method of transmitting health care claims. However, it can be slow and inefficient, and there is a greater risk of errors. Mail is also not a good option for transmitting large volumes of claims.

Electronic Data Interchange (EDI)

EDI is a more efficient way to transmit health care claims than mail. EDI claims are sent electronically from the provider’s computer to the payer’s computer. This process is faster and more accurate than mail, and it reduces the risk of errors. EDI is also a good option for transmitting large volumes of claims.

Web-Based Portals

Web-based portals are another option for transmitting health care claims. These portals allow providers to submit claims electronically through a secure website. Web-based portals are easy to use and they offer a number of features that can help providers to improve their claims processing efficiency, such as:

• Online claim status tracking
• Electronic remittance advice (ERA) processing
• Electronic funds transfer (EFT)

Clearinghouses

Clearinghouses are third-party companies that process health care claims for providers. Clearinghouses can receive claims from providers in a variety of formats, including mail, EDI, and web-based portals. Clearinghouses then convert the claims into a format that is accepted by the payer. Clearinghouses can also help providers to track the status of their claims and to resolve any errors.

Importance of Timely and Accurate Claim Submission

It is important to submit health care claims timely and accurately in order to ensure that patients receive the benefits they are entitled to and to avoid delays in payment. Late or inaccurate claims can also result in denials, which can be costly for providers and patients alike.

Here are some tips for timely and accurate claim submission:

• Submit claims as soon as possible after services are provided.
• Review claims carefully for errors before submitting them.
• Use the correct claim form and coding.
• Include all required documentation, such as medical records and prior authorization numbers.
• Follow up with payers on claims that are not processed within a reasonable time frame.

Conclusion

Health care claim preparation and transmission is a complex process, but it is essential for providers to understand in order to ensure that patients receive the benefits they are entitled to and to avoid delays in payment. By following the tips outlined in this chapter, providers can improve the efficiency of their claims processing and maximize their reimbursement.