Healthcare providers submit medical insurance claims for reimbursement of services provided to patients. Each claim is carefully reviewed by the insurer through a process called claim adjudication. This process has several stages that review each claim for errors, accuracy and policy allowances. After each claim is reviewed, the medical insurer sends a form called a remittance advice to the healthcare provider. This form summarizes each claim submitted by the healthcare provider for all claims within a certain period of time. Each claim is either approved or denied for reimbursement with a summary of the approved cost or a reason for the denial.
It is the responsibility of the medical insurance specialist or medical billing and coding specialist to review over each claim that is listed on the remittance advice to be sure that the insurer has properly reimbursed the healthcare provider. This reconciliation process is important because it identifies any discrepancies that may have caused a claim to be denied. If the denial was due to a clerical error, like a truncated code, then the claim can be resubmitted with the necessary corrections.
The reconciliation process requires each claim on the RA to be matched with the claim submitted by the healthcare provider. This is done by verifying that each claim has the correct claim control number that was assigned to the claim before submitting it to the insurer for processing. This will be part 1 of a three part series addressing the subject of reviewing remittance Advice. Tomorrow we will talk more specifically about the verification process and what a medical billing and coding specialist must verify before submitting a claim.