Billing process
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Provider creates charges and either enters them in their own software or gives them (and any needed demographics) to the biller to enter.
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Biller sends charges/claims to clearinghouse after entering them if needed. 2 possible outcomes:
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The clearinghouse rejects the claim. Biller checks the reason for rejection. 2 possible outcomes:
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Biller fixes the claim and re-sends to the clearinghouse (return to the beginning).
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Claim gets paid entirely by insurance.
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Charges go through and are sent to insurance. 3 possible outcomes:
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Claim gets processed/paid by insurance and there is a patient balance.
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Biller cannot fix the claim and requests info from the provider. 3 possible outcomes:
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Provider responds with the needed correction. Biller re-sends the charge(s) to the clearinghouse (return to the beginning).
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Biller fixes claim and re-sends corrected claim to insurance, either through the clearinghouse (return to the beginning) or through a process determined by insurance carrier.
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Claim gets denied by insurance. Biller checks the reason. 2 possible outcomes:
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Biller sends a statement to the patient.
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Provider responds, but does not provide the needed correction. Biller clarifies what is needed or helps you figure out where the info may be found.
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Provider does not respond. (Process for addressing this is individual to provider.)
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Biller cannot fix the claim and requests info from the provider. 3 possible outcomes:
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Provider responds with the needed correction. Biller fixes claim and re-sends corrected claim to insurance, either through the clearinghouse (return to the beginning) or through a process determined by insurance carrier.
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Provider responds, but does not provide the needed correction. Biller clarifies what is needed or helps you figure out where the info may be found.
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Provider does not respond. (Process for addressing this is individual to provider.)
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Billing Process
