What is the life cycle of insurance claim form?

Answer 1

The life cycle of an insurance claim is the process a health insurance claim goes through from the time the claim is submitted by the provider until it is paid by the insurance carrier. There are four basic steps to the life cycle of an insurance claim - submission, processing, adjudication, and payment/denial. Submission is the transmission of claims to an insurance carrier (either manually or electronically). Processing is completed by the payer by collecting information about the patient, provider, and services performed from the insurance claim form. Adjudication is when the services and information reported on the claim is compared to payer edits and the patients health benefits to ensure all information needed is available, the claim hasn't been previously paid, payer rules were followed, and the services billed are covered benefits for the patient. After the adjudication process, claims are either paid or denied by the payer. The payer generates a remittance advice or explaination of benefits to both the provider and policy holder (patient) explaining how the claim was processed. If the claim is paid, a check is mailed along with the explaination. Once the payment is received by the provider it is posted to the patient's account and any remaining balances are billed out to the patient.