The processing of a health claim usually begins at the time of the first contact with a physician in their office. The office staff will begin gathering information about you and your insurance coverage for eventual billing. In the case of surgery all the inpatient and outpatient charges for care are billed under a global fee. This means the presurgical evaluation and management and postoperative follow up for that condition would be covered by that global fee. During this part the office will review you out-of-pocket payment and whether you have reached your limits. In addition they will have to review is you are affected by a pre-existing conditions clause that may affect eligibility for coverage.
One must also remember that for any surgery there will be many providers caring for the patient. Bills will be generated by the surgeon, anesthesia, radiology (if an x-ray was interpreted), a cardiologist (who may have read your EKG), the pathologist (who may have looked at your path specimen) and finally the hospital. Eventually a claim will be submitted using what is called a CMS-1500.
When claims are submitted to the patient’s insurance they are reviewed to determine whether services are covered. They are submitted for coordination of benefits to determine which payer is responsible for reimbursement (treatment for a work-related accident would be paid by worker’s compensation). There are other stages such as Claims Processing during which they verify information of the patient and finally a Claims Adjudication to review the payer and the patient's health plan benefits. Eventually the claim is either denied or paid and an explanation of benefits is mailed to the policyholder and/or patient.