A claim is generated to bill for medical services provided by a provider to member patients. This is the point where the managed care provider reimbursement process is initiated. Click here to read more.

1. Blog: HelpAtHomeCare.com
MANAGED CARE PROVIDER REIMBURSEMENTS – UNDERSTANDING THE WORKING OF
CLAIMS PROCESSES
The entire concept of managed care consulting is a relatively new phenomenon however, there are benefits
associated with that are driving medical institution and professionals towards it in huge numbers. Patients as well as
healthcare service providers have much to gain from it which is why there are is a huge demand in the market for
better plans as well as MCOs who are professionals and reliable. One major issue faced here, however, is
information. The confusions and misconceptions prevalent in the market can often put a damper on the experience
of a care provider with the concept. This is even more relevant in case of managed care provider reimbursements.
Let us look closely at how the entire claims process works and what drives it to better understand the procedural
changes needed at the end of a service provider to adopt the system.
A claim is generated to bill for medical services provided by a provider to member patients. There are many systems
existing that complete the process of recording and transferring this information to the MCO in both electronic as
well as paper based formats. This is the point where the managed care provider reimbursement process is initiated.
Three processes which are essential to claims processing are claims submittal, adjudication, and payment. The claims
submitted must meet government, regulatory, private as well as MCO standards in order to be considered
acceptable. The claims received are then adjudicated on the basis of their relevancy as well as eligibility following
which the money is released to the providers account to reimburse them for the services. This is how the entire
claims process functions.