The Life Cycle of a Surgical Claim

Students need to know these important steps

If you are enrolled in the Medical Billing and Coding program at Branford Hall Career Institute, you already know that processing insurance claims is an important part of the healthcare industry. As a medical biller or coder, you will play a critical role in ensuring that healthcare providers get paid correctly by insurance companies, Medicare, and Medicaid.

Medical Billers and Coders can also be called Health Claims Specialists. One of the key jobs of Health Claims Specialists is to process medical and surgical claims. It is very important to do this job carefully. Claims need to be coded accurately with the patients’ diagnoses as well as the procedures they may have received. Claims need to be filled out correctly and submitted in a timely matter to the correct insurer. As you are learning in your classes, every step in the process needs to be followed accurately.

Where Do Medical and Surgical Claims Go?
Understanding the entire “life cycle” of insurance claims is important to grasping the “big picture” of medical billing. One of our campuses got creative one day and created a helpful guide for understanding the full life cycle of a surgical claim. Take a look at what they wrote, and see if this helps you see where your work fits in!

In the step-by-step guide below, the asterisk (*) indicates steps where the Health Claims Specialist/Medical Biller and Coder may be directly involved.

Steps in Processing a Surgical Claim

1. New Patient Activities

  • Patient completes a patient information form
  • Patient reviews and signs a Financial Policy statement*
  • Health Claims Specialist creates a medical chart (Electronic Health Record)*

2. Initial Encounter

  • Health Claims Specialist collects patient’s co-payment*
  • Doctor sees the patient and recommends surgery
  • Health Claims Specialist completes Encounter form*

3. Surgery

  • Health Claims Specialist submits precertification request to insurance company*
  • Surgery is scheduled*
  • Doctor operates and dictates an operative report

4. Coding

  • Health Claims Specialist reads and abstracts the operative report*
  • Health Claims Specialist assigns CPT procedure codes and ICD-10 diagnosis codes*
  • Health Claims Specialist enters codes into practice management program*

5. Claim Submission

  • Health Claims Specialist creates an insurance claim*
  • Health Claims Specialist sends claim to the insurance company*
  • Insurance company adjudicates the claim, checking for accuracy and medical necessity

6. Insurance Payment

  • Insurance company sends remittance advice to the doctor’s office
  • Payment is electronically transferred
  • Health Claims Specialist posts the payment and adjusts the patient’s account*

7. Patient Payment

  • Health Claims Specialist creates a remainder statement and sends to patient*
  • Patient makes their payment
  • Health Claims Specialist posts payment to the patient’s account and sends a receipt*

How is that for clear step-by-step instructions? We hope this helps to clarify what goes on with medical and surgical claims and how the job of a Medical Biller and Coder is so important!

Do you know someone who may be interested in enrolling in our program? Medical Billing and Coding is one of the 10 career-focused programs provided at the Branford Hall Career Institute. This training course, also called the Health Claims Specialist program, prepares students with skills in electronic health records (EHR), Health IT, Current Procedural Terminology, the International Classification of Diseases (ICD-10) and much more. After graduation, students are ready for jobs in medical offices, hospitals, billing departments, insurance companies, and other healthcare facilities.

Anyone interested in this program can simply give us a call or contact us online. We would be so excited to hear from you!