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LIFE CYCLE OF HEALTH INSURANCE CLAIMS
Terms in this set (7)
the transmission of claims data either electronically or manually to third party payers or clearinghouses for processing.
third party payers and clearinghouses verify the information found in the submitted claims about the patient and provider.
the process by which the claim is compared to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, claim is not a duplicate, payer rules and procedures have been followed, procedures performed or service provided are covered benefits.
this is any procedure or service reported on the ins. claim that is not listed in the payer's master benefit list.
is a procedure or service provided without proper authorization or was not covered by a current authorization.
MEDICAL NECESSITY EDITS
check that procedure codes match diagnosis codes
procedure in not elective
procedure in not experimental
procedures are essential for treatment
procedures are furnished at an appropriate level
once the claim is approved for payment, a remittance advice (RA) is sent to the provider and an explanation of benefits (EOB) is mailed to the policyholder
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