Page 336 - Ebook health insurance IC27
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The Insurance Times
In medical insurance, when a memberutilizes a benefit a claim is incurred. This claim will
usually be incurred at one of the following providers:
(i) Hospitals
(ii) Pharmacies
(iii) Laboratories
(iv) Clinics
(v) Diagnostic Centers; or
(vi) Any other provider of medical services
Claims are submitted for eligible reimbursement of money either by the member himself
or by the provider directly (under direct billing arrangements), thus initiating the claims
processing function.
Claims processing
The claim processing function is structured in the following order and is usually followed
in the same order as mentioned:
1. Submission of claim
2. Acknowledgment of claim receipt
3. Batch creation of the received claim
4. Auditing the claim
5. Data entry of the audited claim
6. Approval of the claim
7. Settlement of the claim
8. Filing of the settled claim
340 Guide for Health Insurance
