As a healthcare provider, submitting professional claims is an essential part of your practice’s financial health. A professional claim is a request for payment of medical services provided by a healthcare provider to a patient. The professional claims process is a multi-step process that begins with the provider submitting a claim to the payer and ends with the provider receiving reimbursement. In this article, we will discuss the professional claims process from submission to reimbursement.

Professional Claims Process in Steps

these are the steps to follow:

Step 1: Gathering Patient Information

The first step in the professional claims process is to gather the necessary patient information. This includes the patient’s name, date of birth, insurance information, and contact information. It is important to ensure that this information is accurate and up-to-date to avoid delays or denials in the claims process.

Step 2: Providing Medical Services

The next step in the professional claims process is providing medical services to the patient. During this step, the provider will document the services provided, including diagnoses, procedures, and treatments. This documentation is critical to the claims process, as it is used to support the claim and ensure accurate billing.

Step 3: Medical Coding

Once the medical services have been provided and documented, the next step is medical coding. Medical coding involves assigning the appropriate codes to the services provided. These codes are used to describe the medical services and procedures to the payer.

There are two primary coding systems used in the professional claims process: the Current Procedural Terminology (CPT) codes and the International Classification of Diseases (ICD) codes. CPT codes describe the medical services provided, while ICD codes describe the diagnosis or reason for the medical service.

Step 4: Claim Submission

After medical coding is complete, the provider will submit the professional claim to the payer. This can be done electronically or by mail. The claim includes patient and provider information, medical services provided, and the corresponding codes.

Step 5: Claim Processing

Once the payer receives the claim, it goes through a process of claim processing. During this step, the payer reviews the claim for accuracy and completeness. The payer also verifies that the services provided are covered under the patient’s insurance policy.

If the claim is incomplete or inaccurate, the payer may reject the claim or request additional information. In some cases, the payer may deny the claim if they determine that the services provided were not medically necessary or covered under the patient’s insurance policy.

Step 6: Reimbursement

The final step in the professional claims process is reimbursement. If the claim is approved, the payer will reimburse the provider for the services provided. The reimbursement amount will depend on the contracted rate between the provider and the payer, as well as the patient’s insurance coverage.

Conclusion

The professional claims process can be complex and time-consuming. However, by following the steps outlined above, healthcare providers can ensure that their claims are accurate, complete, and submitted in a timely manner. By doing so, providers can improve their cash flow and maintain a healthy financial position for their practice.