Guide 8: Understanding Medical Claims Processing

Medical claims processing is the journey from patient care to reimbursement—a multi-step workflow where accuracy, speed, and compliance truly matter. Errors can mean delays, denials, or lost revenue. This guide breaks it down clearly and shows how BillCare automates and optimizes each stage.

1. 📂 Gathering Patient & Encounter Info (Front‑End)

Before care even begins, critical administrative tasks set the foundation:

• Collect demographics: full name, DOB, contact, insurance details

• Verify coverage & benefits: Confirm that your insurance will cover the visit, Check if special permission (called pre-authorization) is needed

• Prepare the Superbill: the summary of services and codes used to build the claim

💡 BillCare advantage: We automatically check your insurance and remind the staff about anything that’s missing—so you don’t get surprise bills later.

2. 📄 Translating Documentation: Turning Your Visit Into Medical Codes (Back‑End)

After your visit, your doctor writes notes about what happened. Then trained staff turn your symptoms and treatments into codes, and these codes explain what was done and why. You can find out more about the codes here, and here’s a brief summary of how they work:

• ICD‑10‑CM for diagnoses (“why” care was needed)

• CPT / HCPCS for procedures, services, and supplies (“what” was done and “what” was used)

💡 BillCare advantage: Our system reads the doctor’s notes and suggests the correct codes to match your care—so nothing gets missed or coded wrong.

3. 📤 Creating and Sending the Claim

Once the codes are ready, the medical clinic sends your information to your insurance company. This is called a claim.

• It includes your details, the clinic info, and what care you received

• The goal is to make the claim “clean”—meaning it has no errors

💡 BillCare advantage: We build and check the claim for mistakes before it’s sent, helping avoid delays or denials.

4. 📬 Getting a Claim Response & Follow‑Up

Once your insurance company receives the claim, they decide:

• What’s covered

• What’s denied or needs more info

• What you or the clinic need to do next

💡 BillCare advantage: We track the claim and let the medical clinic know if there’s a problem—then help fix it quickly, so your care doesn’t get held up.

5. 💵 Posting Payment & Billing You

After your insurance pays its share:

• The medical clinic applies the payment to your account

• If you still owe anything (like a co-pay or deductible), you’ll get a bill

💡 BillCare advantage: We handle payments automatically and send out bills faster—so you understand what you owe and why.

6. 🔄 Managing the Big Picture: Revenue Cycle Management (RCM)

This full-circle process—from registration to final payment—is known as RCM. The medical clinics who provide your service need to stay on top of:

• Who still owes money (you or your insurance company)

• Which claims got denied

• How fast payments are coming in (also known as Accounts Receivable (AR) days)

• Managing credit balances (overpayments must be refunded to avoid penalties)

💡 BillCare advantage: Our dashboard monitors revenue KPIs—claim age, denial rates, AR—while automated alerts ensure no credit balances go unnoticed.

For more information, visit aapc.com

📌 Summary: Claims Workflow & BillCare Smart Support

✅ With BillCare, Claims Processing is Confident and Compliant

With BillCare working in the background:

• Claims are filed faster

• Fewer mistakes happen

• You get billed clearly and correctly