Medical Claims 101: Medical Claims Processing Take note that the health care system is a multi-billion industry, with millions of people relying on specialized professionals whose responsibility is to ensure that the operations of medical care facilities, pharmaceutical companies, pharmacies and medical equipment manufacturers are following the law and policies governing people’s health. Medical claims processing is one of the systems involved in the health care system. Medical claims processing deals with the interaction of health care providers and medical insurance agencies. In order to understand medical billing and coding, it is important to discuss the relationship between health care providers, policy holders and health insurance companies first. Health care providers are private clinics, hospitals, pharmacies, dental clinics, nursing homes, assisted living facility, in-home caretakers and chiropractor, where a patient receives and is billed for health products and services. Insurance companies on the other hand are the ones who provide medical subsidies for qualified patients or policy holders. Insurance policies are different from one company to another and many people have insurance coverage obtained privately, from an employer or from the government. The process involving how insurance companies work follows the same business operation, wherein a policy holder pays a certain amount of money to the insurance company either monthly or annually, which is known as premium. Depending on the terms of coverage, insurance companies would pay in full or partially the medical expenses involved in a policy holder’s hospitalization, a medical operation or medical procedure such as diagnostics and medicines and other medical supplies used. A policy holder is an individual who purchases a health insurance such as a young adult finding a basic insurance coverage to pay all medical expenses more than the deductible, wherein the amount is pre-arranged and should be paid before the health insurance coverage sets in. In medical claims processing, it is initiated by a policy holder who is seeking medical intervention or health care services such as medical consultation laboratory or any diagnostic procedure, surgery or hospitalization. The patient or the policy holder is financially responsible to pay the deductible, for which the amount of money that he agrees to pay before the insurance coverage begins, after receiving the health care service. Once the policy holder provides his insurance details to the health care provider, then the transaction is complete, after all the verification is done. And this is when the transaction between the insurance company and the health care provider starts. The health care provider will ensure that all medical records are included in the medical claim or dental claim processing, and medical coders and billers are the ones responsible for creating this medical records, and they are the ones who send these claims to the policy holder’s insurance company. The insurance company will either accept, deny or reject the claim.What Has Changed Recently With Billing?