This process helps mitigate errors in medical coding and reduces the time to receive provider reimbursement. Clearinghouses then scrub, standardize and screen medical claims before sending them to the payor. Healthcare providers transmit their medical claims to a clearinghouse. National Drug Code (NDC), if applicableĪ medical claims clearinghouse is an electronic intermediary between healthcare providers and payors.Each new claim detail, or service record, contains the following information: The claim detail includes information about secondary diagnoses or procedures administered during an inpatient hospital stay. Name of the patient’s insurance company.National Provider Identifier (NPI) for the attending physician and the service facility.The claim header also contains details like: This includes confidential patient information like date of birth, gender and zip code. The claim header summarizes the most essential information in the claim. In a medical claims file, this information is split in two parts: the claim header and the claim detail. What information does a medical claims file contain?Įvery medical claims file contains details specific to each patient and patient encounter. In a value-based care model, length of stay and 30-day readmissions impact provider reimbursements. Insurance providers, or payors, assess the medical codes to determine how they will reimburse a provider for their services. When a provider submits a claim, they include all relevant medical codes and the charges for that visit. The medical codes describe any service that a provider used to render care, including: This bill contains unique medical codes detailing the care administered during a patient visit. What is a medical claim?Ī medical claim is a bill that healthcare providers submit to a patient’s insurance provider. In this blog, we’ll help you learn the basics about medical claims: what they are, where they come from and what they mean. It can be difficult to do all this without fully understanding medical claims data. Healthcare organizations can use this claims information to: All-payor claims contain detailed diagnosis and procedure information for any billable patient visit. Medical claims are some of the most valuable sources of data for healthcare organizations.
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