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Comprehensive Guide For Medical Claim Creation

Master Medical Claim Creation: A Step by Step Guide claims processing medical claims processing revenue cycle management


Medical claims processing is lengthy and complicated due to the strict regulations. In today’s blog we’ll discuss how to submit an error free claim. Fortunately, there is high-quality billing software available that greatly simplifies the process. Still, the best approach to take charge of your billing process is to understand each phase and what it includes. Your relationship with billing will improve greatly after you understand the particulars, the reasoning behind each step, and the measures you can take to avoid future mistakes. If you don’t believe us, try following these guidelines the next time you have to file a medical claim and see for yourself what a difference it makes.

Best Practices For Medical Claim Creation

Patient Questionnaire and Registration

Personal information such as name, DOB, address, medical history, and current visit reason are collected. These are just a few examples of the kinds of details that service providers will be asked to give to register. When creating a file for a new patient, it’s important to get as much information as possible. Patients currently being treated should also be questioned thoroughly to ensure the accuracy of any data collected. It’s tempting to skip this step, but that’s usually where the biggest problems arise. Make sure you do everything right during registration so you can file a valid claim afterward.

Examine Proof of Insurance

The verification of a patient’s insurance coverage is a crucial first step. Get the new patient’s insurance information and provider’s contact details. It is equally crucial to verify that the provider and insurance for the requested treatments are current while dealing with a returning patient. Medical Claims processing may be delayed or even refused if erroneous insurance information is recorded.

Superbill development

The superbill is only a document that details the patient’s information, insurance coverage, the appointment’s services, and the applicable New Jersey diagnostic and billing codes.

Medicinal Bill Preparation

This is it, the time has come. The process of making the medical claim has begun. There’s no need to hurry through this step now that you have everything you need to file a medical claim. You’ve been cautious thus far; now is not the time to start taking chances. Verify the accuracy of all billing and coding using software for healthcare organizations, which routinely checks for billing mistakes.

Submit the Medical Claim

Medical Claims processing may be easily submitted with the touch of a button utilizing medical billing software. After ensuring there are no mistakes, your system submits the claim for evaluation by the insurance company. Another advantage of electronic billing is that reimbursements will be processed much more quickly than they would be if you submitted paper claims processing. However, the exact amount of time it takes to get payment might vary widely depending on several factors.

Follow the Progress of the Medical Claims Processing

If you filed your claim online, you may check on its progress at any time. You’ll hear back from the payers after they’ve had a chance to evaluate it. There are a few potential outcomes here, the best of which is that your claim is paid in full. A claim might be wrongly processed, refused, or paid if even a single piece of information was inaccurate. The next step is to make the required adjustments and wait for payment.

Write the Patient’s statement

If there is still a balance, then go to this step. It’s time to send the patient an invoice for the outstanding balance, if any. Total cost, insurance coverage, payment, and any outstanding amount should all be included in this document.   If necessary, do a follow-up with the patient.  Send a reminder call or email to the patient if they haven’t paid their bill by the specified date.

Key Components Of Medical Claims Processing And Creation Process

Accurate charge capture helps you submit a claim that has a greater chance of being paid. The next step is to actually make the claim and then check it over for mistakes.  Information from the patient’s medical record and other billing-related paperwork must be gathered by the coding team. To submit insurance claims processing to third-party payers, codes are necessary. Manual or automated processes are used to convert codes into bills throughout the claims processing generation process.

Correct medical coding results in fewer refused claims processing by health insurance companies. The term claims processing scrubbing refers to the process of verifying claims processing before submission to insurers. Medical facilities may count on correct payments when they submit claims processing promptly.

Some fundamental features of the claims processing making and cleaning procedure are as follows:


Claims processing, which details the care that a patient receives, is often compiled using information from a superbill. Claims processing is generated by medical billers by manually or electronically entering data from the superbill into a practice management (PM) system.

Claim submission forms

Most secondary insurance companies accept Medicare’s CMS-1500 claim form. Different claim forms may be necessary for Medicaid and other third-party payers.

Erasing Medical Claims Processing

Scrubbing refers to the process by which medical billers and coders check for mistakes when preparing claims processing. This aids in making sure that all the data is accurate and full, such as patient information, provider details, visit details, and procedure, diagnostic, and modifier codes. The objective is to produce a flawless claim and avoid rejections. There’s talk of automating the claims processing-checking process in large part.

Tools for Modifying Medical Claims Processing

Errors in submitted medical claims processing, such as those with missing CPT code modifiers or inaccurate diagnostic codes, are easier to spot with the use of editing software. You may anticipate having your claims processing reviewed in light of CMS’s National Correct Coding Initiative modifications, designed to ensure accurate coding. Integration between your EHR and PM system and claims processing scrubbing software ensures that claims processing are invoiced at the correct amount, coded correctly, and processed as rapidly as feasible.

Make use of a Rule Engine for Cost Review

The comparison of your charges to Medicare, Medicaid, and private payer standards may be performed automatically with the help of a charge review rules engine. The rules engine applies millions of coding rules to the supplied charges from the EHR   before importing them into the PM system. It flags inaccuracies so that they may be fixed before a claim is sent to the payer. The requirement for tedious, time-consuming human evaluation of charges is mitigated by a charge review rules engine.

Resolve recurring code problems

Locate the root cause of recurring claim modifications if you see a pattern of mistakes. Get in touch with the right biller, coder, doctor, or other staff member so the issue may be fixed. If you want to avoid repeating the same error, you need to make sure the right details are recorded. Provide personnel with training on how to identify and rectify such mistakes and inconsistencies if they keep cropping up.


knowing how to submit medical claims processing is crucial for doctors’ and hospitals’ survival. It’s like getting all the right pieces of the puzzle in place before payment happens for seeing patients. It means collecting quite a bit of information from patients, ensuring their insurance is active, and generating this specific record called a super bill. Next, they have to be super cautious while filing the real claim. With the use of computers, they can conveniently submit these medical claims to insurance firms, which is much faster than paper. And then they wait and see how much money they get to get back to work, and then they’ll figure out what needs to be fixed. That’s why mastering the medical claims processing is essential for doctors and hospitals to be compensated correctly and to serve their patients well.


What are the steps in making a claim?

Making a medical insurance claim typically involves the following steps:

  • Patient Questionnaire and Registration: Obtain personal information from the patient (name, date of birth, address, medical history, reason for visit). Document this data for accuracy comprehensively.
  • Examine Proof of Insurance: Confirm the patient’s insurance eligibility and obtain their insurance information, including the plan name, number, and the provider’s contact number. Verify insurance information is updated and correct.
  • Superbill Development: A superbill file should include patient information, insurance details, services rendered during the appointment, and the corresponding diagnostic and billing codes.
  • Medical Bill Preparation: Start the medical claims procesing to check the medical billing and coding correctly. Check for billing errors using the software.
  • Submit the Claim: Send the claim electronically using medical billing software to the insurance company. This accelerates the payment process compared with Paper claims processing.
  • Follow the Progress of the Claim: Check the status of the claim online. Wait to receive answers from the insurer, including maybe, full payment, errors, or claim denials. Adjustments may be needed.
  • Write the Patient Statement: Send an invoice to the patient with details of the total cost, insurance coverage, payments made, and the remaining balance (if any). If necessary, send reminders in return.

This process is seamless and helps doctors to generate and submit medical claims processing in time, and also make the payment and records accurate.

How do I make a medical billing claim?

Making a claim in a clinic is a vital phase that helps healthcare providers receive compensation for their medical care correctly.

To begin with, collect detailed patient data during the Patient Registration stage. It contains personal data, medical records, as well as insurance policies. Given that claim denials can result from errors in the initial claims processing data collection process, it’s important.

Then, create a superbill that captures all the patient information, the services provided, and relevant diagnostic and billing codes. The accuracy of these keys because this is what tells the insurer how much to pay. Check for any coding errors using billing software.

As soon as everything is aligned submit the claim electronically with the help of medical billing software. Submission through electronic form is quicker than submitting via paper and also reduces the chance of errors in the claim. Submit your claim and follow its progress; be sure you’re ready to assist with any processing issues or claim denials. Timely, accurate submission combined with follow-up improves the chances of receiving a claim payment for medical services.

How many diagnoses can be reported on the CMS 1500?

There is room to report several ICD-10 diagnoses on a single CMS-1500 claim form, used for billing insurance providers for healthcare services provided to patients. The CMS-1500 form has room for as many as twelve diagnosis codes (ICD-10). It allows the health professional to record various medical problems/reasons for the patient’s visit in just one visit. These codes provide insurance companies with information on medical necessity for services provided and for how much they will be compensated.

Since patients usually have complex medical problems and multi-morbidity requiring detailed reporting, the ability to report several diagnosis codes on the CMS-1500 claim form is vital. Providers must record accurate information about a patient’s health status and treatments. This additional complexity is handled by the CMS-1500 Form which allows as many as twelve diagnosis codes to be included on the form thereby ensuring that all medical information required by the insurance carrier for proper billing and reimbursement is being communicated.

What is the process of medical billing?

This is a structured approach in the healthcare industry where medical practitioners submit the bills to insurance companies or patients to get paid for the services they have provided.

The first step is patient registration and information gathering. Personal data, health insurance information, and medical history of patients are all collected and recorded if they receive medical attention. It is important because, for claim submission, precise patient data is needed.

The second step is about issuing an assert to claim and submit. The visit concludes and the provider generates a thorough claim, with much help from the superbill. In this statement: the number of patients, services performed, the diagnose codes, the procedure codes, and cost numbers. It’s then either digitally or by paper forms sent, to the patient’s insurance company, or direct to the patient for payment.

Finally, the medical claim processing and compensation stage is involved. Doctors should keep track of their claim progress and insurance companies need to review them for accuracy and fullness. Insurance companies might take in the claim and pay us back reject it due to mistakes, or refuse it for one reason or another. If there are problems, providers have to fix them, fix the fixes, and resubmit if necessary. It is hoped that payment comes in for the services provided and ultimately ensures healthcare organizations stay afloat, and medical professionals get paid, while preserving patients’ records and accurately billed.

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