Dissecting the Success of an Insurance Claim.pdf

Improve efficiency and profitability of your orthopedic practice by optimizing workflow. Learn about the benefits of redesigned EHR systems.

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Dissecting the Success of an Insurance Claim
Let's diagnose a healthy claim!
A healthy heart rate line that ends with a checkmark, symbolizing a successful claim process.
Claim
Submission
Submit the
completed claim
form to the
insurance company.
Clearance
Checkpoint
Pass the claim
through a
clearinghouse for
initial checks and
validation.
Payer
Processing
Insurance company
reviews the claim
for approval, denial,
or further
investigation.
Payment
Posting
Record the
received payments
into the patient’s
account.
Denial
Management
Identify and
address the
reasons for any
denied claims.
Follow-Up
Monitor the claim’s
progress and follow
up as needed.
Patient
Responsibility
Calculate and
communicate the
patient’s
out-of-pocket costs
and copays.
Coding
Accuracy
Ensure that all
medical procedures
and diagnoses are
coded correctly.
Insurance
Verification
Confirm the
patient’s insurance
coverage and policy
details.
Patient
Information
Gather and
document all
necessary patient
details accurately.