What is a Claim Statement in Medical Billing

Medical billing is the process that regulates the financial give and takes between the patients (first-party), health care provider (second party) and the insurance company or payer (third party). The medical billing is administered by hospitals to receive payment for the medical care provided by the hospital doctors. The payment is requested from the patient and the insurance payer only after generating the superbill. This superbill is then converted into a claim statement and is beneficial while making claims for reimbursement.

But exactly what is the claim statement in medical billing?

The medical coder generates the superbill which is then put into a paper claim format by the medical biller. This is done by using medical billing software for the utmost accuracy. The medical billing and collection company mentions the cost of all the procedures received by the patient as part of medical care along with their charges. It is important to note that the bill is generated to claim the reimbursement for the procedures mentioned in it. Therefore, the biller is obliged to ask for the amount that has been promised by the insurance payer as per the patient’s insurance plan. This bill generated to claim insurance reimbursement is called a claim statement.

The format to generate the claim statement varies from hospital to hospital. However, there is some information that is common in various formats of claim statements. The information that is required to be mentioned in a claim statement includes the patient’s demographic and medical history details and CPT or HCPCS codes paired with an ICD code for the procedures performed by the physician to treat the patient. In addition to this, the claim statement also mentions the National Provider Index (NPI) number about the provider’s information and the Place of Service code.

Furthermore, to generate an error-free claim statement the medical biller must follow the billing guidelines as given by the Health Insurance Portability and Accountability Act (HIPAA) and the Office of the Inspector General (OIG). Meeting the standards of billing compliances is one way to prevent denied claims.

A carefully prepared claim statement in medical billing will surely boost your hospital’s revenue cycle by raising the reimbursement claims to the maximum. It will also improve the quality of medical care by allowing your doctors to focus on treating patients without worrying about their finances.