Insurance company’s attempt to streamline operations to contain and direct claim payments so that insurance premium funds are used efficiently.
Insurance Encyclopedia
Claim Cost Inflation
The rate of increase in the cost of claim payments. It is likely to be influenced by many different types of inflationary force, e.g., general or specific salary inflation, general or specific price inflation, court award inflation.
Claim department
The insurance company’s department that assesses whether claims will be paid.
Claim edits
Electronic examination of transmitted insurance claims for errors, conflicting code entries, and a match of diagnosis to medical service(s) provided. Also called edit check. See front-end edits.
Claim expense
The expense of adjusting a claim, such as investigation and attorneys’ fees. It does not include the cost of the claim itself.
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The costs, other than the actual claim cost, that are associated with paying a claim.
Claim Expenses
Fees charged by the Loss Adjuster/Surveyor, Investigator, Attorneys designated by the Insurance Company or by the insured with the company’s written consent and all other reasonable and necessary fees, costs and expenses resulting from the investigation, adjustment, defense and appeal of a claim if incurred by the insurance company or by the insured with the written consent of the insurance company, including, but not limited to, premiums for any appeal bond, attachment bond or similar bond but without any obligation of the insurance company to apply for or furnish any such bond. Claims expenses with respect to a claim may be paid first and may or may not include fees, costs or expenses of employees or officers of the insurance company.
Claim file
Accumulation of information needed for payment or denial of an insurance claim.
Claim Form
An application for a claim.
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MEDICAL,USA: Document that is completed detailing the medical services rendered to a patient by the provider or facility and submitted to the insurance company for payment.
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MEDICAL,USA,REFERENCE: See: Health Insurance Claim Form (CMS-1500).
Claim fraud
Intentional misrepresentation by either providers or patients to obtain services, payment for services, or claim program eligibility. In insurance claims, fraudulent practices are intentionally double billing for the same services, reporting diagnoses and procedures to maximize payments, billing for services that were not performed, and so on.
Claim frequency rate
In health insurance calculations, this is a value obtained from the expected percentage of insured individuals who will file claims and the number of claims they will file within a specific period of time. This rate is used to calculate average claim costs, which are used to establish premium rates.