What Happens after Claims are Submitted?

What Happens after Claims are Submitted?



What Happens after Claims are Submitted?

A claim in the field of healthcare is a request for reimbursement that the client or the care provider submits for the aim of ensuring the provision of the products or services required. In today’s age, various platforms can be used in order to ensure the submission of claims. Nowadays, healthcare providers advocate for the utilization of electronic media. Particularly, persons can initiate and submit medical claims online. Nonetheless, the process that takes place after the submission of claims tends to be convoluted. Following submission, the process will focus on determining the type of claim option requested for by the patient. Usually, different medical claims exist. In fact, the main elements of healthcare insurance comprise Medicare and Medicaid. Apart from these examples, others constitute claims settled by Managed Care organizations, health management organizations (HMOs), and preferred provider organizations (PPOs), and Point of Service (POS) plans (Thurber, 2011).

 HIPAA regulations require that most submissions be electronically computed. However, there are several exceptions to this particular rule. For instance, companies with fewer than 10 employees may utilize manual claims (Thurber, 2011). In addition to this, a medical practice with a sufficient power outage may present claims manually especially if such claims are limited by time. The evaluation of the medical claims that have been submitted pave way for assessments concerning whether the claim needs to be accepted or denied. Once the variables have been determined, the claims are then billed by the insurance organization or the third-party payer (Thurber, 2011).. In this process, other variables need to be assessed as well. They comprise elements such as the insurance plan for the patient, the guidelines established by the payer concerning claim submission, and the contract between the provider and the payer.


Thurber, P. (2011). Claims medical manual. Palo Alto, CA: Pacific Books.

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