Claims Processing

Written by Norene Anderson
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Claims processing has changed drastically from the paper claims of the 1970s when every line had to be filled in by hand or typed in with an electric typewriter. This time-consuming process has given way to the current technological provision for filing claims electronically. Standardized forms and codes for medication, diagnosis, and procedure identification have changed the speed and efficiency of processing claims.

The current methods of claims processing offers the capacity to monitor trends in drug pricing, procedures, and many other types of information. Healthcare insurers can access nationwide databases to compile data from across the country or in a specific region. This is a great benefit for physicians, pharmacies, and pharmaceutical companies. The information is readily available and that is a vast difference from the manual compilation of statistics in years past.

Claims Processing Criteria

Claims processing is an ongoing project. The databases must be kept up-to-date with the latest drug identification codes. With the large number of drugs added to the market every year, it requires vigilance to keep the programs current. The process of determining the allowable reimbursement fee on each drug is specific to the type of insurance benefits of each plan. A central location for all data makes it easier for pharmacists and payers to handle claims efficiently.

It is necessary for payment schedules for drugs and biologicals to be paid according to the latest defined guidelines in relation to the AWP (Average Wholesale Price). Different providers such as Medicare and managed care providers calculate the reimbursement on a percentage of the AWP. There are always exceptions to the guidelines. Every detail should be entered correctly to expedite the processing of insurance claims.

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