Medical claims

A medical claim is a formal request by providers or patients to health insurers for payment of medical services. Insurers process medical claims submitted by hospitals, doctors, and clinics using codes such as ICD-10 and CPT; for example, code 99213 represents an office visit.

Claims can be denied due to incorrect patient data, missing codes, or lack of preauthorization, with denial rates ranging from 5% to 10%, as seen in Medicare Advantage data from 2022. Patients submit out-of-network medical claims for reimbursement after paying upfront for covered procedures like physical therapy or diagnostic imaging, as confirmed by YourInsurance.info.

Insurers typically pay approved claims directly to providers within 30 days, according to federal prompt pay requirements. Common supporting documents include itemized bills and explanation of benefits (EOB), which summarize insurer decisions regarding each charge.

Electronic Health Record (EHR) systems automate medical claims filing in large practices such as Mayo Clinic and Cleveland Clinic. Claims audits performed by insurers identify billing errors or fraud; the National Health Care Anti-Fraud Association estimates $68 billion lost annually due to fraud, some detected via audit of abnormal claims volume.

Patients appeal denied claims by submitting written requests along with new clinical evidence, and the Kaiser Family Foundation reports that only 0.2% of denied marketplace claims were appealed in 2021. Medical claim forms are standardized as CMS-1500 for individual providers and UB-04 for institutional services; examples include surgeries, chemotherapy sessions, or radiology scans.

HIPAA requires insurers to maintain privacy for all submitted claim information, enforced by fines up to $1.5 million per violation as recorded by HHS statistics.