Health & Benefit Payers are highly investing in Automated Claim Processing Systems with an emphasis on interoperability & attainment of efficient claim processing. These flexible, fully-featured and easy-to-use systems can create clean claims with great ease.
Claim Process begins when a healthcare provider has submitted a claim request to the insurance company for reimbursement. An automated end-to-end process is activated with the help of Claims Processing Software. This software works on everything from claim creation to adjudication tracking to reimbursement. It involves three primary steps that are Claims Adjudication, Explanation of Benefits (EOBs), and Claim Settlement.
In Claim Adjudication, health & benefit payers use automated verification for adjudication of claims. After the adjudication process is complete, the health & benefit payers or insurance company sends an Explanation of Benefits (EOB) that details how the medical care you’ve received will be paid by your insurance plan. Based on the EOB the claim payment or benefit is generated.
Main Players of Healthcare Claim Processing System
To understand the claims processing & benefits management process, it is important to know the group of organizations involved in the claim processing systems &recognize the relationship between healthcare providers, insurance firms, and policyholders.
Policyholders
The policyholder is the one who purchases health insurance. Like suppose, a young professional is looking for a basic insurance plan can purchase a policy where their insurance provider firm will be paying for all medical bills that costs more than deductible, which is a pre-decided amount that policyholder will be required to pay out-of-pocket before insurance coverage kicks-in.
Insurance Companies — Insurance companies sponsor medical care for policyholders. The insurance policies may vary, but all of them work under the same business rule where a specific amount is paid each month or year by policyholders to the insurance company, and it is called a premium.
Healthcare Providers — This is any practice or facility where the patients are billed for a service or a product related to personal health. This group of healthcare providers consists of private clinics, hospitals, pharmacies and also specialized care providers, such as nursing homes, in-home caretakers & chiropractors.
How Claim Processing Systems help in Claim Processing & Benefits
Claims Processing Software are the automated tools used to streamline the entire claims process, maintain & manage the claims. These are designed to achieve complete automation of claims processing and faster access to customer information without comprising on confidential information.
Such systems are beneficial in decreasing costs related to claims processing, functions within a single platform for all the data sources, workflows to route claims for review & approval processes & improve consistency & suitability of payments.
Advanced Claims Processing Software offers functionalities like:
- Auto-Adjudication& Integrated Solutions
- Rapid Deployment & Implementation
- Easy to use &Robust Features
- Highly Scalable & Super Configurable
- Super Service & Support
Claim Processing Systems have transformed insurance claim handling, earlier a labor-intensive process into a fully automated & integrated process.
