Health insurance claims processing is the work an insurer does on every claim it receives: it checks the claim, decides how much to pay, and pays the hospital or clinic. In the United States, this work is done by health plans, which is what Americans call health insurance companies, and by state governments. Health plans there handle billions of claims a year.
An American claim is checked in three ways. First, it is checked against the patient's plan: does the plan cover this treatment? Second, it is checked against the plan's contract with the clinic: how much may the clinic charge? Third, it is checked against medical rules: do the codes billed make sense together? Then the claim is priced and paid. Most claims pass all three checks with no person involved. People, many of them in India, review the complex, denied and appealed claims.
The health plan administration system is the insurer's core system. It holds the members, the plans and the contracts. Health plan benefits configuration sets up each plan's rules inside it. Claims editing software checks the codes. Claims adjudication and administration decides each claim. Payment integrity checks that the amount is right, before and after payment. Healthcare payments sends the money to the clinic, with details of what each payment covers.
Around the claims run three more jobs. Prior authorisation is the insurer's approval before an expensive treatment. Care management software helps members with serious illnesses get the right care. Value-based care for employers is a newer kind of plan that pays doctors for keeping people healthy. For Americans on low incomes, each state runs Medicaid on a Medicaid management information system (MMIS).
In India, the same job looks different. Most claims are cashless claims, decided by the insurer or a third-party administrator (TPA) while the patient is still in hospital. IRDAI, the insurance regulator, sets time limits for these decisions. The National Health Claims Exchange (NHCX) carries these claims between hospitals and insurers in one format. Inside an Indian insurer, they are recorded in the claims management part of its core system.