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Lesson 11: Claims Processing (Reasons for the issues (Bill exceeded…
Lesson 11: Claims Processing
Types of claims
First Party Claim - from patient directly
Third Party Claim - patients paying their medical bills through other agencies other than by themselves
Cicil Service (payment for employee medical benefits)
Private organization/employers/insurance companies of the patients (letter of guarentee)
CPF - Patients' own
Medisave
Medishield Life
Integrated Shield Plan
Claims are usually sent electronically via respective healthcare institutions IT systems (LOGs are claimed manually)
Not all claims can be process due to various reasons
Bill Amendment
Staff (front line, nursing and other departments) will raise a bill amendment form to the business office
Amendment form needs to be approved by the relevant parties
Supervisor in-charge
Business office in-charge
Higher authority if amount exceeds a certain limit
Once approved - staff may proceed to make necessary adjustments and regenerate the bill and submit the claim
Claim Processing Issues
Denied Claims
Rejected Claims
Reasons for the issues
Bill exceeded claimable amount (double claim - service entered twice)
Non claimable item sent (e.g. cosmetic items/services)
Patient no longer eligible for 3rd party claims (no longer a civil servant/no longer covered by insurance)
Wrong information sent (wrong patient information (NRIC, Name, DOB etc)
Insufficient information sent (missing claim amount)
Wring date of birth entered (new requirement by CPF for verification)