Medical Insurance Billing and Claims Processing

A complete workflow for medical practices to handle insurance billing from patient check-in through payment collection. This Tallyfy template covers eligibility verification, coding, claim submission, payment posting, denial management, and patient collections. Takes 2-4 weeks per claim cycle depending on payer response times. Best used by medical billing specialists, office managers, and revenue cycle teams.Timeline: 2-4 weeks per claim cycle (payer dependent) Best for: Medical billing specialists, office managers, revenue cycle teams, practice administrators Compliance: Supports HIPAA-compliant billing workflows and documentation requirements Key stages: Check-in - Eligibility - Coding - Charge Entry - Submission - Payment - Denials - Patient Collections Reduces: Claim denials, aging receivables, coding errors, and timely filing issues

9 steps

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Process steps

Patient check-in and demographics verification

5 days from previous step

task

Collect the patients full name, date of birth, address, and contact details. Capture their insurance information including the payer name, policy number, and group ID. Double-check spelling on everything - a wrong letter in a name can cause claim denials down the road. If the patient is new, scan a copy of their insurance card for the file. Required information: - Full legal name (as it appears on insurance card) - Date of birth - Current address and phone number - Insurance card (front and back scan for new patients) - Policy/member ID and group number - Subscriber relationship (self, spouse, dependent)

Insurance Eligibility and Verification

5 days from previous step

task

Before the patient sees the doctor, confirm their coverage is active. Call the insurance company or use the online portal to verify eligibility, check copay amounts, and identify any deductibles. Look for pre-authorization requirements - some procedures won't get paid without it. Note any coverage exclusions so there aren't surprises later.

Medical Coding of Diagnosis, Procedures and Modifiers

5 days from previous step

task

Review the physician's notes and translate them into ICD-10 diagnosis codes and CPT procedure codes. Pick the most specific code that matches - vague codes get audited and denied. Add modifiers when needed, like -25 for separate E/M services. If the documentation is unclear, don't guess. Send a query back to the provider for clarification.

Charge Entry

5 days from previous step

task

Enter all coded services into the billing system with the correct date of service and provider information. Match each charge to the right insurance plan. Watch for duplicate entries - they cause headaches later. Run the charge lag report weekly to catch anything that's been sitting too long without being entered.

Claims submission via clearinghouse

5 days from previous step

task

Submit claims electronically through the clearinghouse. Check the scrubber report first - it catches common errors like missing NPI numbers or invalid diagnosis code combinations. Most payers want claims within 90 days of service, though some are stricter. Keep a record of the claim number and submission date for tracking. Pre-submission checklist: - Run claims scrubber and fix any errors - Verify NPI numbers for rendering and billing providers - Confirm diagnosis codes support medical necessity - Check for correct place of service code - Attach required documentation for high-dollar claims Timely filing deadlines (common): - Medicare: 12 months from date of service - Medicaid: 90 days (varies by state) - Commercial: 90-180 days (check contract)

Claim status follow-up and aging review

14 days from previous step

task

Check unpaid claims at 14, 30, and 45 days after submission. Use the payer portal or call the provider line to verify receipt and get status updates. Claims sitting in pending status may need additional documentation. Flag anything approaching timely filing limits for urgent attention. Follow-up milestones: - Day 14: Verify claim received and in processing - Day 30: Check for pending requests or missing info - Day 45: Escalate unpaid claims, request supervisor review Aging report priorities: - 0-30 days: Monitor, no action needed - 31-60 days: Active follow-up required - 61-90 days: Urgent - risk of timely filing - 90+ days: Critical - immediate action or write-off review

Payment Posting

5 days from previous step

task

Post payments from the ERA (Electronic Remittance Advice) to each patient account. Match the payment amount to the expected reimbursement - if it's short, flag it for follow-up. Adjust off any contractual write-offs according to the fee schedule. Transfer patient responsibility amounts to the patient balance for billing.

Denial management and appeals

1 day from previous step

task

Review denied claims within 48 hours of receiving them. Check the denial reason code - sometimes it is a simple fix like a missing modifier. For clinical denials, gather supporting documentation and write a clear appeal letter. Know your deadlines: most payers give you 60-180 days to appeal. Common denial categories and actions: - CO-4 (modifier): Add or correct modifier and resubmit - CO-16 (missing info): Provide requested documentation - CO-50 (non-covered): Check medical necessity, appeal with clinical notes - PR-1 (deductible): Bill patient for their portion - CO-97 (bundled): Review NCCI edits, consider modifier 59 Appeal requirements: - Reference the original claim number and date of service - Include copy of the EOB with denial reason - Attach supporting clinical documentation - State specific appeal grounds with citations

Patient billing and collections

1 day from previous step

task

Send patient statements promptly after insurance pays their portion. Make the bill easy to understand - confusing statements lead to ignored statements. Offer payment plans for larger balances. Follow up with a phone call after 30 days, another statement at 60, and consider collections at 90-120 days if there is no response. Statement best practices: - Send within 7 days of insurance payment posting - Include clear itemization of services and charges - Show insurance payment and adjustments - Provide multiple payment options (online, phone, mail) - Include contact info for billing questions Collection timeline: - Day 0: First statement sent - Day 30: Second statement + phone call attempt - Day 60: Third statement, payment plan offer - Day 90-120: Final notice, collection agency referral consideration