Medical Insurance & Billing


As the new Reimbursement Manager, you have to give an orientation to departmental employees.

Create a presentation, using MS Powerpoint, to outline your presentation. You’ll want to also provide some basic information on types of claims, relationship to insurances, and the life cycle of a claim. Then, discuss items that may be gathered to prepare to process the claim.

At a minimum, your presentation should be at least 8 slides to include:

  • Introduction – the new Reimbursement Manager
    • Your role and responsibilities
  • Types of claims (paper and electronic)
  • Main differences between paper and electronic claims
    • Note the process used at your facility -paper or electronic
  • Importance of EDI.
  • Life Cycle of an Insurances (four basic steps)
  • Common Reasons for Claim Rejections/Delays
  • Summary



Extra Information:


Types of Claims

Processing an insurance claim essentially starts with completing the health insurance form. The health insurance claim form is a standard form that was created in 1958. The form itself was approved by the AMA as a universal claim form in 1975. The universal claim form was originally called the Health Insurance Claim Form (HCFA-1500) but is now called the CMS 1500. To better understand how claims are processed, let’s review the types of claims.

Paper Claim
A paper claim is a claim submitted on paper, this also includes optically scanned claims that are converted to electronic form by insurance companies. Paper claims may be typed or generated via computer.

Electronic Claim
An electronic claim is one that is submitted to the insurance carrier via dial-up modem, direct data entry, or over the Internet by way of digital subscriber line. Electronic claims are digital files that are not printed on paper claim forms when submitted to the payer.



Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) is transmission of information between computers using highly standardized electronic versions of common business documents.

Encryption is the translation of data into a secret code. Encryption is the most effective way to achieve data security. To read an encrypted file, you must have access to a secret key or password that enables you to decrypt it. Unencrypted data is called plain text ; encrypted data is referred to as cipher text.

Optical Scanning
Optical scanning is used across the nation in processing insurance claims because of their speed and efficiency. Take a look at some of the things you want to make sure you do, while also taking a glimpse at the things you absolutely do not want to carry out.

The Do’s and Don’ts of Optical Scanning


  • Do: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons.
  • Do: use original claim forms printed in red ink; photocopies cannot be scanned.
  • Do: align the typewriter or printer correctly so characters appear in the proper fields.
  • Do: enter all information in upper case letters.
  • Do: use alpha or numeric symbols.
  • Do: enter eight-digit date formats.
  • Do: keep signature within signature block.


  • Don’t: allow characters to touch lines.
  • Don’t: use script, slant, minifont, or italicized fonts or expanded compressed, bold, or proportional print.
  • Don’t: handwrite information on the document.
  • Don’t: strike over errors when correcting or crowd preprinted numbers.
  • Don’t: use highlighter pens or colored ink.
  • Don’t: use symbols (#, -, /), periods(.), ditto marks, parentheses, or commas(,).
  • Don’t: use N/A or DNA when information is not applicable.


The Life Cycle of an Insurance Claim

The life cycle of an insurance claim is basically the processes followed the collect information, complete and submit the insurance claim for payment. Although there are many details that can vary based on the facility and complexity of the claim, there are four basic steps – submission, processing, adjudication, and payment/denial.

Click here to learn more about the process.

Common Reasons for Claim Delay or Rejection

Regardless of the type of claim, both can be delayed or rejected for various reasons.

  • Claim submitted to the secondary insurer instead of the primary insurer.
  • Information missing on patient portion of the claim form.
  • Patient’s insurance number is incorrect or transposed.
  • Patient’s name and insured’s name are entered as the same when the patient is a dependent.
  • Failure to indicate whether patient’s condition is related to employment or an “other” type of accident.
  • Patient’s signature is missing.
  • Physician’s signature is missing.

Click here to learn more about the process.


Clearinghouse refers to a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and “value-added” networks and switches, that does either of the following functions:

  1. Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.
  2. Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity.

Transactions are activities involving the transfer of health care information for specific purposes. Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), if a health care provider engages in one of the identified transactions, they must comply with the standard for that transaction. HIPAA requires every provider who does business electronically to use the same health care transactions, code sets, and identifiers.