Insurance Companies consider several factors when paying a claim in an ambulatory care setting. For instance, the insurance company may not pay a claim if the claim form is incomplete or dirty. It is therefore important to understand the various terms used by the insurance companies in an outpatient care setting.
Difference between ‘explanation of benefits’ and ‘remittance advice’
An explanation of benefit is a statement issued by the insurance company to the insured persons. The purpose of the statement is to explain which medical services were paid for by the insurer and which were not paid to the health care provider. The patient has to pay for the portion of the services that are not paid for by the insurance company. Remittance advice is a statement sent to the healthcare provider. The statement explains the reasons for adjustment made on payments or the details for denial of payments. Also, the details of the uncovered charges are highlighted in the document. Both explanations of benefits and remittance advice have almost similar contents. However, they are different in that while an explanation of benefits is sent to the insured individuals, the remittance advice is issued to the health care provider ("The Difference Between the Explanation of Benefits and Remittance Advice", 2019).
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Clean, Dirty and Incomplete Insurance Claim Forms
Clean claim forms are those that have been correctly filled and completed without errors and omissions. All the details pertaining to the medical insurance claim are provided. The processing of clean claim forms is fast and payments are made promptly to the health care provider. Dirty claim forms are those that have been filled and submitted to the insurer but contain errors and omissions. The forms have to be corrected and resubmitted to the insurance company. Sometimes, manual processing of the claim is done and this may delay payment. Incomplete claim forms are those that have missing information concerning the insurance claim ("The Health Insurance Claim Forms Chapter 20 Flashcards by ProProfs", 2019). The forms have to be corrected and resubmitted to the insurer for the payments to be processed. An incomplete claim is also known as an invalid claim.
References
The Difference Between the Explanation of Benefits and Remittance Advice. (2019). Retrieved from https://smallbusiness.chron.com/difference-between-explanation-benefits-remittance-advice-36842.html
The Health Insurance Claim Forms Chapter 20 Flashcards by ProProfs. (2019). Retrieved from https://www.proprofs.com/flashcards/story.php?title=health-insurance-claim-forms-chapter-20
