What Does a Medical Insurance Claims Processor Do?

Processing insurance claims is best done by people. Although automated computer systems can scan a claim for information, make a decision to pay or deny, then issue a check or denial letter accordingly, more often than not, a human touch is required.

Function

The function of a Medical Claims Processor is to provide that human touch. When medical insurance claims fall out of the realm of "yes-or-no" questions and land in the "maybe" category, a claims processor uses her resources to complete the claim. Because medical insurance plans are so individualized, it is essential that the claim processor be proficient in reading and understanding each plan's terms.

The Facts

A Medical Insurance Claims Processor is responsible for reviewing a medical claim for accuracy and validity. She compares the billed medical procedures to the insured's specific plan benefits. It is her job to decide if the items billed fall within the insurance member's plan provisions. If more information is needed to make this determination, she informs the insurance member. Generally, the claims processor is working within a computerized claims processing program that helps flag any claims requiring specific attention.

Time Frame

Insurance regulations dictate the amount of time before a claim must be either paid or denied, once it is received by the insurance company. The amount can vary according to each plan's description. State mandates require timely processing of a claim. A Medical Claims Processor is responsible for knowing how long she has to complete each claim.

Benefits

Due to the close nature that the processor has with each policy, she is familiar with the specifics of your plan. If you have questions regarding the way your medical claim was processed, questions can always be directed back to the claim processor. A Medical Claims Processor will have work standards to which she will be held accountable, just like any other professional.

Misconceptions

When medical claims are denied, it may be tempting to think that the person processing the claim is responsible. While she may have mailed your denial, she was only processing a claim per the plan's benefit description. Some think that all Medical Claims Processors are instructed to deny all claims as a way to save the insurance company money. This is an illegal act and any insurance company found to be participating in such practices would face legal action.

References

• Insurance Processor
• Medical Billing Jobs and Updates