Every medical claims file has information about each patient and each time they saw a doctor. This information is split into two parts in a medical claims file: the claim header and the claim detail.
Make a claim
The claim header is a short summary of the most important parts of the claim. This includes things like the patient's date of birth, gender, and zip code, which are private. The claim header also has information such as:
National Provider Identifier (NPI) for the attending doctor and the service facility
Primary diagnosis code
if applicable, an inpatient procedure
Group about diagnosis (DRG)
Name of the insurance company for the patient
Cost of the claim as a whole
Claim detail
Information about secondary diagnoses or procedures done during a hospital stay as an inpatient is included in the claim detail. Each new service record, which is a detail of a claim, has the following information:
Service date
Procedure code
Corresponding diagnosis code
If there is a National Drug Code (NDC),
NPI number of the attending physician
Put a price on the service
What is a center for clearing up medical claims?
A medical claims clearinghouse is an electronic middleman between the people who provide health care and the people who pay for it. Medical claims are sent to a clearinghouse by healthcare providers. Before sending them to the payer, clearinghouses clean, standardize, and screen medical claims.
This process helps cut down on mistakes in medical coding and shortens the time it takes for providers to get paid. If there are mistakes in the medical coding or the way the claim is formatted, the payor could reject it. This means that the claim would have to be sent again, which would delay the provider getting paid.
Payors also get something out of the service that clearinghouses offer. Clearinghouses put together data on medical claims based on what each payer needs. By standardizing the data in this way, payors can speed up the process of billing for medical care.
