Improving Claims Processing Procedures

Claims Processing Tools

To maximize payment and reduce the administrative costs and frustration related to claims processing, practices should periodically review their claims processing procedures. Such assessments can ensure that practices maintain correct payer information, verify eligibility, provide correct information on each claim and follow-up with payers with corrected claim information and appeals as necessary. Incorrect claim information, improperly completed claim forms or plan members who are no longer eligible result in delayed or denied payment. Maintaining current and accurate payer information and completing claim forms correctly will reduce denied and delayed claims payments.

A collaborative effort of health plans and medical specialty societies through the Specialty Society Insurance Coalition developed resources for payers and providers on claims processing. This work group included physicians from medical specialty organizations, representatives of health plans, the Healthcare Financial Management Association (HFMA) and hospitals who agreed to work together to identify ways that health plans and providers can improve claims processing efficiency by decreasing duplicate, ineligible and delayed claims. The following documents were developed to facilitate efforts to improve claims processing efficiency.

Click on the links provided below to access the most recent version of the forms.

 Improving Claims Processing and Payment: A Self-Assessment Tool

This checklist form is intended to assist practices in assessing their process for submitting claims. Reviewing the questions can provide a better understanding of the processes for generating and tracking claims and identify opportunities to improve payment and accounts receivables.

Coordination of Benefits: Tips for Reducing Payment Delays and Improving Accounts Receivable

To address payment delays due to coordination of benefits, this brief guide provides tips on collecting information on patient benefit information and using that information to improve claims processing and payment.​