Medical Claims Process Checklist: From Start to Finish

Filing medical claims the right way helps healthcare providers get paid faster. Errors in this process can lead to an increase in rejected or denied claims, which means more work and lost revenue. Alternatively, claims that are processed correctly are less likely to contain errors and more likely to move through the system smoothly and quickly.

Medical claims processing doesn’t have to be stressful. Implementing the right strategy can help your office submit clean claims, prevent common problems, and improve cash flow.

This guide will break down each step of the medical claims process, from checking a patient’s insurance to tracking payments. The goal is to provide a clear checklist to help you create claims that are less likely to contain errors and more likely to move through the system smoothly and quickly.

Patient Information & Eligibility Verification

Before submitting a claim, collecting accurate patient details and confirming their insurance coverage is important. Missing or incorrect information can result in claim rejections, slow down payments, and require extra work.

Collect Accurate Patient Information During Patient Intake

Ensure all patient details, such as name, date of birth, and insurance ID, are correct. Even minor errors can cause claim rejections. Double-check that contact details are up to date for billing and follow-ups. Using a patient intake solution can make sure you gather all of the necessary information.

Verify Insurance Eligibility & Benefits

Use an insurance eligibility verification tool to confirm coverage before treatment. Check for active policies, coverage limits, and exclusions to avoid surprises later. This should be done before the patient visits your office and again when they check in, just in case anything changes.

Obtain Required Pre-Authorizations

Some procedures and treatments require approval from the insurance provider. Failing to get pre-authorization can result in unpaid claims. Always check the insurer’s requirements in advance.

Provide Transparent Co-Pays & Deductibles

Let patients know what they owe before their visit. Explain co-pays, deductibles, and out-of-pocket costs clearly. This will help prevent confusion and billing issues later.

Medical Coding & Documentation Accuracy

Accurate coding is essential for submitting clean medical claims and ensuring timely reimbursement. Coding errors often lead to claim denials, delayed payments, or compliance issues. A thorough review of documentation and codes helps prevent these problems.

Fill In Correct ICD-10, CPT, & HCPCS Codes

Every claim must include the correct diagnosis and procedure codes. Use the latest ICD-10, CPT, and HCPCS codes to describe the patient’s condition and treatment. Incorrect or outdated codes can cause rejections or underpayments.

Properly Link Diagnosis Codes to Procedures & Care

Diagnosis codes must match the treatments and services provided. If there’s a mismatch, insurers may deny payment. Always ensure that diagnosis codes accurately justify the procedures listed on the claim.

Ensure Codes Are Entered Before Submissionv

Before submitting a claim, double-check that all required codes are included. Missing or incorrect codes can require time-consuming corrections and resubmissions. A careful review helps avoid these issues.

Claim Creation & Submission

Once you have verified all patient and coding details, the next step is creating and submitting the claim. Accuracy is key—errors or missing information can lead to rejections and payment delays. A structured review process ensures claims are complete before submission.

Conduct a Thorough Review of Claim Details

Before sending a claim, double-check patient information, insurance details, procedure codes, and billing amounts. Even small mistakes can cause rejections. Careful review helps avoid costly setbacks.

Validate the Medical Claim to Ensure It Contains All Necessary Information

Every claim must include essential details, such as provider information, diagnosis and procedure codes, and correct billing amounts. Using a clearinghouse can help catch some of these errors before submission and helps ensure your claims meet payer requirements.

Submit the Claim in Real-Time or as a Batch

Claims can be submitted individually in real time or in batches at scheduled times. Real-time submissions allow for quick corrections if errors are detected, while batch submissions can streamline workflows for high-volume practices.

Claims Tracking & Denial Management

Even well-prepared claims can face issues after submission. Regularly tracking claims helps catch problems early. A strong denial management process ensures that rejected claims are corrected and resubmitted quickly or that a denied claim is appealed.

Monitor Claim Status After Submission

Once a claim is submitted, be sure to track its progress. Many insurers provide online portals to check claim status in real-time or you may be able to do this in your clearinghouse. Regular monitoring helps identify delays and allows for quick action if issues arise.

Identify & Address Rejections

Claims can be rejected due to missing information, incorrect codes, or eligibility issues. Rejections typically require simple fixes and can be resubmitted quickly. Reviewing rejection reports from payers helps identify trends and prevent future errors.

Effectively Appeal Denied Claims

If a claim is denied, an appeal may be necessary. A well-organized denial management strategy helps identify common denial reasons, gather supporting documentation, and submit appeals quickly.

Payment Posting & Reconciliation

Payments must be accurately recorded once a claim is processed to keep financial records current. Proper reconciliation ensures that all payments match expected reimbursements, helping prevent revenue loss and billing errors.

Review Electronic Remittance Advice (ERA)

The ERA provides details about insurance company payments. It typically includes approved amounts and adjustments. Reviewing these reports helps identify discrepancies or denied charges that may need follow-up.

Post Payments in the System

Payments must be entered correctly into the practice’s billing system. Healthcare software can often automate this process, reducing manual errors and ensuring financial data stays organized.

Address Any Discrepancies or Underpayments

If a payment doesn’t match the expected amount, it’s important to investigate. Strong revenue cycle management practices help identify underpayments, appeal incorrect adjustments, and recover lost revenue efficiently.

Patient Billing & Collections

After insurance payments are posted, any remaining balance is billed to the patient. A clear and efficient medical billing process ensures patients understand their financial responsibility. They can then make prompt payments without confusion or delay.

Provide Clear & Timely Patient Statements

Patients should receive detailed, easy-to-understand statements outlining their charges, insurance payments, and any remaining balance. Sending bills promptly reduces payment delays and improves cash flow.

Offer Online Payment Options & Financing Plans

Providing flexible payment options makes it easier for patients to settle their bills. Many medical billing systems include online portals where patients can pay electronically. Offering financing plans for larger balances can also help reduce unpaid bills and improve collection rates.

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