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.
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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.
Claim investigation
Process of obtaining insurance claim information to decide if a claim should be paid by the insurance company.
Claim lag
1. Time period between the patient’s encounter (incurred) date of the insurance claim and its submission to the third-party payer. 2. Time period between the incurred date of the insurance claim and its payment by the third-party payer.
Claim list
Data evidence of claims paid under an insurance plan or coverage for a specific time period. Such lists include identification of the insured, cause of the insurance claim, description of service, and amount paid.
Claim Made Basis Liability Coverage
A Method of determining whether or not coverage is available for a specific claim. If a claim is made during the time period when a liability policy is in effect an insurance company is responsible for its payment, up the limits of the policy, regardless of when the even causing the claim occurred. Typically this type of coverage is endorsed with a prior acts date or retroactive date before which the insurance company has excluded coverage.
Claim manual
Administrative guidelines documented in a book used by insurance claims adjusters to settle (adjudicate) claims for payment according to the insurance company’s policies and procedures.