What It Takes to File a Medical Insurance Claim | Harris Casel Institute Melbourne FL
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What It Takes to File a Medical Insurance Claim

medical insurance claim process, medical billing and codingA medical billing and coding specialist plays an important healthcare role in facilitating this process

Even though you probably use your health insurance on a regular basis, you might not realize that there’s a profession dedicated to getting this process going after you leave your doctor. It’s called a Health Claims Specialist, and this is the first step in a chain of events that results in your doctor getting compensated for the service they provided to you.

The Harris Casel Institute offers a professional training program that provides students with the medical billing and coding skills they need to perform in this essential role. We prepare students to work in a range of environments, from doctors’ offices and hospitals to other medical facilities.

It can be helpful to have an overview of how a health claim is processed. For example, a claim that originated in a medical billing office might follow a process like this:

1. Gathering information and database entry

During a visit, the medical biller or coder makes a copy of the patient’s insurance card and enters the patient’s information into a database.

2. Insurance verification and communication

If the patient is new, or has obtained new insurance since his or her last visit, the billing and coding specialist may consult with the patient to determine whether:

  • the practice accepts the patient’s form of insurance
  • the patient understands the details of the coverage, and how it applies to the current visit.

3. Recording patient services

After doctors, nurses, or other healthcare providers have seen the patient, they capture this information as part of an Electronic Health Record (EHR) system. This includes details about the examination and any diagnosis, treatment, or services performed.

4. Collecting payment from the patient

Before the patient leaves the facility, he or she will make a payment for the portion of the services that the insurance requires (called a “co-pay”). This could mean that the patient pays nothing, if the service is fully covered, or that the patient must pay for the entire cost up front, which constitutes an “out of pocket” expense. All of the fees collected at this time go directly to reimburse the medical office or practice.

5. Choosing a code

An essential step for the medical coder is to select the appropriate diagnosis and procedural codes. He or she looks at the EHR, and chooses codes from the International Classification of Diseases (ICD-10) and/or a list of procedural terminology. Accuracy here is critical, because if this determination is not precise, then the medical office will not receive the proper reimbursement from the insurance company.

6. Submitting a claim

Once the codes have been selected, and there is documentation of payments made by the patient, is it time to generate the insurance claim. The billing specialist prepares the claim and submits it, either to the insurance company, Medicare, or Medicaid. The process can vary slightly depending on which insurance the patient has.

7. Receiving payment for service

Presuming that the billing specialist has prepared the claim accurately and correctly, the insurance company will compensate the medical practice for its services. It is also the medical biller’s role to post the payment to the account of the medical practice.

8. Following up as needed

If the medical practice does not receive a payment in a timely manner, the billing specialist is charged with doing some investigation to determine why this has not occurred. In some cases this may require revising claims that might have been submitted with incorrect information.

Has learning about this process piqued your interest in medical billing and coding as a career? If so, we hope you will reach out to us to learn more. A job in this valuable profession could be in your future!


The Harris Casel Institute provides a number of professional training programs at its campus in Melbourne, FL. We invite you to learn more by visiting us online.