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All About Healthcare Claims Processing Workflow4 min read

Healthcare Claims Processing Workflow
Let’s ease and explain your Healthcare Claims Processing Workflow, A detailed guide on how it works, and how to improve your workflow.

If we discuss ways to increase efficiency in the processing of medical claims, we should start at the very beginning. A claim travels a long way from when a patient schedules an appointment until the bill is paid.

There are a few strategies for streamlining the Medical claims process and making it more efficient. Some clogged-up claims management processes may be alleviated through consolidation, outsourcing, and AI advancements. Process simplification might prevent delays in your facility’s insurance claims processing.

How to Streamline Healthcare Claims Processing Workflow?

You will see all the various steps a claim takes to reach its destination in the healthcare claims processing workflow below. If procedures aren’t clear and well-organized, processing claims may take a while. A claim should be limited to the number of hand-offs in your facility.

Even though HIPAA includes rules and regulations governing how claims should be processed electronically, some manual processes are still necessary. Furthermore, the chance of inaccuracy increases the more hands a claim passes through. In this situation, outsourcing is used.

To accurately deliver the bill to the payer, a piece of data must pass through at least a dozen processes. Paper medical records are one of the processes still in use today. Still, there are ways to assure their accuracy, which applies to behavioral health claims processing and increasing productivity in this convoluted workflow.

Step 1: Submission

Frequently weeks after the appointment, the doctor’s billing department submits a claim to a clearing house, where it is processed for computerized data entry. 

Step 2: Initial Review

Inaccurate or inconsistent doctor/facility information is one of the most frequent problems with claims. An algorithm checks the patient’s medical claims process for duplicate charges, errors, incomprehensible text, and erroneous information. 

Step 3: Qualification 

The system confirms that the patient is a member with an active insurance plan by comparing his name and policy number to the Insurance provider’s database.

Step 4: Adjudication of Benefits

The system contrasts the patient’s services with his insurance plan’s benefits. It determines if the Insurance provider covers each service and how much it will pay according to the specifics of his plan.

Step 5: Examine the Medical Necessity

The system examines the patient’s claim to make sure the things his doctor charges are safe for the patient, compliant with industry best practices, and medically essential. By taking this measure, the patient will avoid paying for services he doesn’t require.

Depending on the services provided, each line-item charge, and the overall amount charged on the bill, the system flags the claim as low-risk or high-risk for insurance fraud. The assertion made by the patient is alow-risk.

Step 6: Insurance Check

The insurance firms do the following checks during this phase:

  • Has pre-approval been granted?
  • Do the details on the claim match those in the pre-authorization request?
  • Does the patient qualify to submit a claim?
  • Has the claim been duplicated in any way?
  • Is the hospital on the list of authorized networks?
  • Is this diagnosis accurate?
  • Was the procedure medically required?
  • Has the procedure been correctly coded?
  • Is the amount of the claim request verified?

Step 7: Adjudication

For the adjudication of claims, insurance companies use a combination of computerized and manual verification. Payment determination is completed after the insurance company determines how much it is willing to pay for the claim.

When the adjudication procedure is finished, the insurance provider notifies the hospital and includes information about their findings and their reasoning for accepting (totally or partially) or rejecting the claim. An explanation of benefits or remittance advice is what this is called. The healthcare provider may offer extra details or ask to represent the claim per the EOB.

Step 8: Make a Payment

Under Patient’s benefits, Insurance Provider sends a payment to the Patient’s physician for the sum the Insurance Provider covers based on negotiated rates. The patient might be liable for the full sum if he hasn’t satisfied his deductible.

Step 9: Benefits Explanation (EOB)

To explain how much the doctor charged, how much Insurance Provider paid, and how much the patient would still owe in out-of-pocket costs, the Insurance provider develops an explanation of benefits. He double-checks his EOB to ensure that all the data is accurate and that it corresponds to the services he received.

Step 10: Bill

The doctor’s office will send the patient a bill if a payment is necessary; the amount and services indicated on the statement should line up.

How to Improve Healthcare Claims Processing Workflow with Transcure

With the use of electronic health records (EHR) and the Trans Capture app, you can excel in medical billing and coding; even behavioral health claims processing will help you a lot. When processing medical claims for your members, using a BPO agency to handle your claims management services can be very advantageous. The claims management services cover every aspect, including; quality assurance, provider and member matching, and contact with health insurance companies.

Claims management outsourcing might free up time and resources for other projects at your business. Additionally, it can help you prevent problems like turnover and training while saving money. Additionally, outsourcing teams can make the painful negotiation processes easier. It can make a world of difference to have a representative looking out for both your suppliers and members.

Andrew Mark
Andrew Mark
As a healthcare IT expert, I bring extensive experience in revenue cycle management (RCM), medical billing, and coding. I am passionate about simplifying complex healthcare processes and empowering providers with efficient solutions.



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