All About Medical Claims

December 9, 2021

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At StayWell we strive to keep our members informed on their rights and responsibilities so that we can work together for healthier future. This month we focus on everything you need to know about medical claims; what they are, how they work, and what you need to do to ensure that you get the best care at the best price available.

What is a Medical Claim?

A medical claim is a bill that healthcare providers submit to a patient’s insurance provider. This bill contains unique medical codes detailing the care administered during a patient visit. The medical codes describe any service that a provider used to render care, including:

  • A diagnosis

  • A procedure

  • Medical supplies

  • Medical devices

  • Pharmaceuticals, and

  • Medical transportation

When a provider submits a claim, they include all relevant medical codes and the charges for that visit. Insurance providers, or payers, assess the medical codes to determine how they will reimburse a provider for their services. In a value-based care model, length of stay and 30-day readmissions impact provider reimbursements.

What Does the Medical Billing Process Look Like?

The medical billing process contains seven essential steps. These steps trace the entire claims journey from the moment a patient checks in at a healthcare facility, to the moment they receive a bill from their insurance provider.

Patient registration

Patient registration is the very first step in the medical billing process. Registration occurs when a patient gives their provider personal details and insurance information.

Insurance Eligibility Verification

After a patient has registered, the care provider must verify the patient’s insurance. This helps to confirm that the patient has adequate coverage for the care that they will receive. Verification helps care providers determine coverage and eligibility, and assess the following:

  • What the patient’s policy benefits are

  • Patient’s co-insurance or co-payment

  • Whether the patient has accumulated co-pay, deductible, or out-of-pock expenses

  • Whether the patient’s insurance provider requires pre-authorization

Medical Coding

Medical coding is a critical step that occurs after care has been administered. Care providers transcribe their notes and other clinical documentation into standardized medical codes. Some of the most common medical coding systems include:

  • Diagnosis-related group (DRG)

  • Current Procedural Terminology (CPT)

  • Healthcare common procedure coding system (HCPCS)

  • International classification of disease (ICD-10), and

  • National Drug Code (NDC)

Care providers use these codes to describe which medical diagnoses, procedures, prescriptions, and supplies they administered and why. The specificity of medical codes also helps providers describe the patient’s condition.

Charge Entry

Charge entry is the last step before care providers submit their claims for payment. Providers or medical billing specialists list the charges of services provided to patient

Claims Transmission

Claims transmission is when claims are transferred from the care provider to the payer. In some cases, claims are first transmitted to a clearinghouse. The clearinghouse reviews and reformats medical claims before sending them to the payer.

In other cases, healthcare providers send medical claims directly to a payer. High-volume payers like Medicare or Medicaid may receive bills directly from providers. This helps to reduce the time that it takes to receive reimbursement from high-volume payers.


Adjudication occurs once the payer has received a medical claim. The payer evaluates the claim and decides two important things:

  • Whether the medical claim Is valid, and

  • How much of the claim payer will reimburse

If the claim is accepted, the payer will issue provider reimbursement. The payer may deny the claim if the plan does not cover the service, if the plan maximum has been met or if the provider did not get pre-authorization for a service. If a payer denies a medical claim, the patient may have to submit an appeal to gain coverage for the care costs.

The payer may also reject a claim. This happens when the claim does not meet formatting requirements or contains an error in medical coding. Rejected medical claims can be resubmitted for payment once the errors have been corrected.

Patient Statement

Patient statement is the final step in the medical billing process. Once the payer has reviewed a medical claim and agreed to pay a certain amount, the provider bills the patient for any remaining costs.

Medical Claims & Your StayWell Member Rights

Services at a participating provider are based on eligible charges. When you receive service from a participating provider for treatment, that provider will submit your claim to StayWell Insurance. Payment will be made directly less any amounts that patient/member is responsible for (e.g., applicable coinsurance/copayments, or not covered expenses) Covered services will be paid provided the provider of services bills StayWell within ninety (90) days after the date in which the service was rendered, unless otherwise required by law.

If you receive services from a non-participating provider, StayWell will pay only a percentage of eligible charges (please see your summary of coverage/schedule of benefits for details). The company has no agreement with non-participating providers and they may charge you more than the eligible charge for any service.

The eligible charge for services by a non-participating provider will be less than for a participating provider. You are responsible for paying the specified coinsurance/copayment plus any amount by which the provider’s charge exceeds the eligible charge.

How to Make a Medical Claim

When a participating provider treats you, that provider will submit your claim to our office. However, if you should receive treatment from a non-participating provider you must pay for the services and then seek reimbursement from StayWell, unless the provider agrees to file the claim on your behalf. Request your reimbursement by sending your itemized bill and original receipt within ninety (90) days after the date in which the service was rendered to StayWell Insurance

When an off island dental provider, outside of the United States treats you, you must request the provider to complete an off-island dental claim form and submit the completed form with an original receipt for reimbursement. You may obtain the form at the StayWell office or on our website.

Working Together for a Healthier You

Knowing and understanding your member rights and responsibilities allows us to better serve you so that we can work together for a better, healthier you. Take full control over your health insurance benefits by taking the time to read and understand your member handbook which you can find here; and always be sure to check out our Member's Corner page to find the most up-to-date documents and forms for your health insurance benefits..