What is Medical Claims Processing? Why Outsource Medical Claim Processing?


The medical insurance sector is highly competitive, and new schemes are announced day-in and day-out. An agreement is created between the insurer and the insurance company as a bond to acknowledge the insurance. In times of needs and difficulties, the amount insured along with a few benefits promised by the insurance company can be claimed.

The process of claiming the amount insured can be done through electronic or manual claim forms. Usually, standard claim forms are applicable for managing under ten employees. If you run an organization with over ten employees, you will be required to fill the claim forms electronically. To help organizations in the medical insurance claim processing, a few outsourcing companies are available. You can outsource the process of insurance claiming to these agencies that’ll reduce a lot of workload for the employer.

Process of a medical insurance claim

The method of claiming medical insurance involves filing a claim and continuous check on the submitted application. The medical claim process involves three essential steps:

  1. Adjudication
  2. EOB
  3. Settlement


It is the verification of claims that are claimed by the insurer. The insurance companies check the pre-authorization and proceed with further confirmation. The check will include the type of disease, the amount requested, and it is the claimed illness that requires medical attention, the cost of treatment, and so on.

Besides, the insurance company will also check if the hospital comes under the network of claimable hospitals for treatment.


EOB stands for an Explanation of Benefits; once the verification of all the above said adjudication is completed. The insurance company sends a letter explaining all the benefits that can be covered under the policy.

The explanation will have the following details in it:

  1. Amount paid beforehand
  2. The amount approved presently
  3. Allowable amount
  4. Patient responsibility amount
  5. Covered bills
  6. Discount amount
  7. Details of covered bills


Claim settlement is the final phase in which the insurance company will provide the due amount that is claimed in the medical claim processing. It is done either for the individual or as a bulk for the filed employees in the organization.

Outsourcing medical claim processing

Outsourcing medical claim processing is beneficial for the organization because outsourcing company will take care of the filing and frequent follow-ups. The following are the benefits of outsourcing medical insurance claim processing:

  1. Turnaround time is quick – Delivery of the settlement will be ready in time if you employ a third-party outsourcing company for the claim processing.
  2. Scalability – Bulk processing of claim forms will be made easy for organizations with employees of over 500.
  3. Better efficiency – The procedures and filing of applications are done with accuracy, and the time of delivery is also quick.

Today, we have advanced multiple options like automated medical claim processing. Automated processing is done electronically and with just a few inputs to reduce the manual work and stress on the organization or individual who is filing the claim.

Leave a comment