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What Are the Different Types of Claims Processing?

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  • Written By: Staci A. Terry
  • Edited By: Allegra J. Lingo
  • Last Modified Date: 06 December 2016
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Many industries use some type of claims processing, including the insurance and healthcare industries. The most common types of claims processing include the processing of medical claims and all types of insurance claims. Some companies handle their claims processing themselves, but others choose to send them out to third party claims processors, usually due to sheer volume of claims. Electronic claims processing software use is also common, which can greatly improve the efficiency and speed of claims processing.

One of the most common types of claims processing is insurance claims. All insurance companies use claims processing systems for policyholders to submit claims for coverage under the relevant insurance policy. Once a policyholder files a claim, which he typically does by contacting the insurance company directly, the insurance company forwards the claim to a claims examiner to evaluate the claim against the applicable insurance policy. The claims examiner then determines any coverage available under the policy and recommends the claim for denial or approval. Once the claim has been denied or approved, the policyholder can then accept the decision of the claims examiner or further appeal the decision in attempt to secure coverage or better coverage than what the claims examiner has offered to pay out on the claim.

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Insurance claims can occur in the context of auto insurance policies, such as when a car accident has caused property damages or personal injuries, or in the context of homeowner’s insurance policies, where the homeowner has suffered a loss or an accident has occurred on the premises. For instance, a person involved in a car accident might file a claim against the insurance policy of the responsible party. A homeowner might file a claim against his homeowner’s insurance policy if a tornado or a hailstorm causes damage to the roof of his home.

In the healthcare industry, a person who pays premiums for medical insurance coverage, for instance, submits his insurance information to any medical providers that he visits for treatment. The provider will typically file a claim directly with the medical insurance company of the patient. Some providers have contracts with insurance companies involving certain negotiated rates for particular services. The providers may or may not bill the portion of the claim that remains unpaid by the insurance company to the patient. This practice usually depends on the insurance policy provisions, which may limit the liability of the patient for any such expenses to a fixed amount, such as in the case of a copayment.

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