Claims processing

Can anyone who have real experience in claims processing.could me please explain me testing process in claims processing..thanks

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Claims processing is the the entire process of entering the procedures rendered until payment is collected or denial is determined. These procedures might be in the context of Medical Claims. When we talk of Claims Processing in Information technology, we talk about the applications developed for medical insurance industry.

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  • Aug 1st, 2010

Mainly, there are three types of claims as below
1. Professional 2. Outpatient 3. Inpatient.

There are different types of plans like PPO, HMO, HSA, etc.
These plans are assosiated with different contracts which have different types of benefits.

In Claim Processing there are mainly two types
1. Manual Processing (Detail & Summary Type)
2. System Adjudication

We have to enter the claims for the members under the above said plans.
Then we have to log the claims into the system.
If the claim goes for System Adjudication, after the batch run, we have to check whether the benefits are applied to the claim properly as mentioned in the contract assosiated with the plan.
If the claim goes for Manual Processing, then we have to manually process the claims.
There will be a setting in the system like if we press a function key say F2, then the benefits will be applied systematically. so, we have to manually process the claim by pressing F2 and verfiy whether the benefits are applied properly.

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  • Sep 26th, 2015

Could you please explain how to perform testing on the claim process module and what are the possible test scenario and test case will be there?

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