Collect the patient’s personal information, insurance details, and verify coverage eligibility.
Purpose: Ensures that the patient’s insurance is active and covers the intended services.
The healthcare provider documents the services provided to the patient in the EHR.
Purpose: Accurate documentation is essential for proper coding and billing.
Medical coders translate the documented services into standardized codes (ICD-10 for diagnoses, CPT for procedures).
Purpose: These codes are necessary to create a claim for insurance reimbursement.
The billing department enters the codes into the billing system to create a claim.
Purpose: This step generates the claim that will be sent to the insurance company.
The claim is submitted to the insurance company, usually electronically.
Purpose: The insurance company reviews the claim to decide on the payment.
The insurance company processes the claim by reviewing the codes and patient’s coverage.
Outcome: The claim is either approved, partially approved, denied, or additional information is requested.
Once the insurance company makes a payment, it is posted to the patient’s account.
Purpose: This reduces the patient’s balance according to the insurance payment.
If there is any remaining balance after insurance payment, a bill is sent to the patient.
Purpose: The patient is informed of the remaining balance they need to pay.
The billing department follows up with the patient for any outstanding balance.
Purpose: To collect the remaining amount from the patient.
The patient pays the remaining balance, and the account is settled.
Purpose: This final step closes the billing cycle with the account marked as paid in full.
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