Jul 01, 2021 Admin

Healthcare EDI

What Are The Types of Health Insurance Claims?

The Healthcare sector is one of the fastest departments that is growing in the American economy. However, it is one of the most expensive units too if you are not financially enough to dip your savings into paying medical bills and charges. What makes sense is to go for healthcare insurance claims. But, do you know there are many people across there who are not aware of various medical coverages.

Yes, you read it right! If you are one of them, don’t worry, we will help you to know what a health insurance plan is and its types. But wait, we will also talk a bit about EDI solutions. Make sure you are reading it till the end. 

What Is a Health Insurance Claim or Mediclaim? 

A healthcare insurance claim is a process in which a medical insurance policyholder submits its request or bills to the insurance company to get the services related to their health insurance policy. The health insurance policyholder has two options, either to acquire a direct claim settlement possibility which is also known as a cashless treatment or they can go with the reimbursed method to avail the healthcare services. 

Through this way, one can submit or request the claim form to the healthcare provider for reimbursement or cashless services, whichever they like. Apart from this, these medi-claim bills contain unique medical codes that have detail for the patient visit. On the other hand, Enterprise Mobility Management Services can also help professionals to get more efficiency and effectiveness. Back to the point, these codes help medical providers with various services such as diagnosis, medical supplies, pharmaceuticals, medical transportation, and so on. Once the patient is done with the services, the providers share a claim with them that contains the charges for their visit through the relevant medical codes. 

Later, the insurance provider examines the medical codes to understand the reimbursement of their services. As we know these healthcare plans are the financial support that you may need in a medical emergency. However, these plans come up with various advantages that everyone can acquire, even the owners of enterprise software development company. 

There are various aspects that revolve around the healthcare plans such as coverage for hospitalization, post-hospitalization expenses, cost of medication for the insured, expenses for when the insured does not earn, the expense of purchasing medicines, cost of emergency services. In conclusion, you need to file a claim to avail of the healthcare benefits as an insured person. 

What Information Is There In The Medical Claim?

Medical Claims comprises two major parts: the claim header and the claim detail. These files own the specific details of each patient they encounter with. We will start this section with an understanding of the claim header first. Before proceeding ahead, make sure to understand the  Healthcare EDI Checklist.

What Is a Claim Header?

This segment under the medical claim summarizes the critical information in the claim. The confidential data of patient such as zip code, date of birth, and gender falls in this category, Not only but the claim header also contains some other data related to the complete charge for the claim, Primary diagnosis code, details of the patient’s insurance company, diagnosis-related group (DRG), National Provider Identifier (NPI) for the attending doctor and the service facility along with Inpatient procedure.

Also, read- How Outsourcing EDI Solution Can Help You Overcome 834 Challenges?

What Is Claim Detail?

Here comes the Claim detail after the claim header. This segment contains the necessary details about the secondary diagnoses or other administrative procedures that happened during an inpatient hospital stay. Claim details consist of the Date of service, a charge for the service, Procedure code, attending physician’s NPI number, National Drug Code (NDC), and Corresponding diagnosis code.  

Hey, wait! Are you aware of virtual healthcare? Now it is important to know about the types of health insurance claims, right? Keeping this in mind we are sharing two major medical claims. 

How Does Medical Claim look? 

This is one of the most frequent questions that every newbie asks in the healthcare sector or someone who is new in the EDI 834 landscape. Let us tell you, the medical claim contains seven major steps, they are as follows: 

Patient registration: This is the primary step in the medical billing process. Once the patient shares their confidential details and insurance information. with their provider, then only registration gets completed. 

Insurance Eligibility Verification: Once the patient has registered himself, the care provider will verify the patient’s insurance to confirm the coverage for the care. 

Medical Coding: This is the critical step that comes after the administration. Care providers now transcribe their notes and other medical documentation into regulated medical codes.

Charge Entry-  This is the last step just before the care providers share the claim for payment. The medical billing executive will list the charges. 

There are various healthcare software that can help you in boosting up your business, back to the point. The above-mentioned steps track the complete claim journey from the starting of the healthcare facility to receiving the bill from the insurance agent. 

Let’s understand the type of Medical Claims: 

It is evident that people are buying medical claims as a promise to support them in tough and challenging times. We are sharing the types of Medical Claims or Health Insurance for you. 

1.      Preferred Provider Organization (PPO)

In this health insurance plan, employees can use a network of hospitals and physicians. In the PPO plan providers are agreed to cater their services at a discounted or negotiated rate. However, employees don’t really need to designate the primary care physician, but they still have the choice to see any doctors or specialists according to their choice within the network.

2.      Health Maintenance Organization (HMO)-- Health Insurance Plans

With this health insurance plan, employees have less flexibility in terms of choosing the choice of physicians or hospitals as compared to other plans. Employees covered under HMO are required to select a primary care physician (PCP), but if they want to see a specialist, it is important to go with PCP.

3.      Point of Service (POS) -- Health Insurance Plans

POS plans conjoins with HMO And PPO plan. Just like these panels, employees can select Primary Care Physician (PCP) from the plan’s network sources. POS is suitable for those who want flexibility while choosing physicians and other sources. 

4.      Exclusive Provider Organization (EPOs) -- Health Insurance Plans

EPO and HMO work on a similar basis for the network of physicians. Employees' members can have Primary Care Physician (PCP) that will help them in providing referrals to in-network specialists. Here, EPO members are in charge of small co-payments and also may require a deductible.

5.      Indemnity Health Insurance Plans -- Health Insurance Plans

It is also called fee-for-service plans for its pre-arranged amounts or portions of costs reimbursed to the member for covered services. The reimbursed member may be in charge of  deductibles and coinsurance amounts.

6.      Health Savings Account (HSA) -- Health Insurance Plans

An HSA is a tax-favored savings account that is utilized in connection with an HSA-compatible to qualify for medical expenses. Health Savings Account can also be conjoined with the group health insurance. It can be owned by small businesses and employees so that they can contribute to the group policy if they want. However, HSA is considered to be a good option for small business owners. 

7.      Health Reimbursement Arrangements (HRAs)

In this health insurance claim, employers reimburse employee’s premiums and even help them with medical expenses. However, Health Reimbursement Arrangements also owns its variation based on the user’s requirements. We shall discuss it later.

The Recap

Here is the list of health insurance claim that one can get benefited from. However, these policies are life-saving as they help an individual to fight in turbulent situations. We do remember we were about to tell you about EDI integration services. This is the perfect way to share confidential information between two parties in fully encrypted mode. One can eliminate manual data work, and also ensure overall productivity at the workplace. 

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