Question

Examples of illogical information found on an INVALID claim are things such as :

1) Provider doesn't match provider name
2) Patient's sex doesn't correlate with procedure
3) Date of birth doesn't make sense for patient

Answer 1

Illogical information on an invalid health insurance claim indicates either data quality issues or potential fraud, which can cause claim denials and payment delays.

Step-by-step explanation:

Examples of illogical information on an invalid claim can significantly impact the processing and approval of healthcare insurance claims. These examples typically signify a problem with the data quality or possible fraud. For instance:

• The named provider on the insurance claim does not match the provider's actual name in the insurer's records.
• The patient's sex does not correlate with the medical procedure code listed (for example, a male patient listed for an obstetric procedure).
• The date of birth is inconsistent, perhaps indicating the patient is too young or too old for the reported procedure.

Accurate claims are essential for the proper functioning of the health insurance system. Invalid claims can lead to claim denials, delays in payment, and need additional verification, impeding both providers and patients.