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Claim preparation

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The medical biller takes the superbill from the medical coder and puts it either into a paper claim form or into the proper practice management or billing software. Biller’s will also include the cost of the procedures in the claim. They won’t send the full cost to the payer, but rather the amount they expect the payer to pay, as laid out in the payer’s contract with the patient and the provider. 

Once the biller has created the medical claim, he or she is responsible for ensuring that the claim meets the standards of compliance, both for coding and format. The accuracy of the coding process is generally left up to the coder, but the biller does review the codes to ensure that the procedures coded are billable. Whether a procedure is billable depends on the patient’s insurance plan and the regulations laid out by the payer. 

While claims may vary in format, they typically have the same basic information. Each claim contains the patient’s information (their demographic info and medical history) and the procedures performed (in CPT or HCPCS codes). Each of these procedures is paired with a diagnosis code (an ICD code) that demonstrates the medical necessity. The price for these procedures is listed as well. Claims also have information about the provider, listed via a National Provider Index (NPI) number. Some claims will also include a Place of Service code, which details what type of facility the medical services were performed in. 

Biller’s must also ensure that the bill meets the standards of billing compliance. Biller’s typically must follow guidelines laid out by the Health Insurance Portability and Accountability Act (HIPAA) and the Office of the Inspector General (OIG). OIG compliance standards are relatively straightforward but lengthy, and for reasons of space and efficiency, we won’t cover them in any great depth here.