Determining Who Claims are Payable to

When adding a claim to an invoice, it's critical to correctly designate the payment recipient. This ensures efficient processing and accurate financial tracking. Below are key considerations for determining how claims should be handled, based on the payment recipient.

Claims Payable to the Clinic or Provider

For claims payable to a clinic or provider, invoices are evaluated with reference to the Explanation of Benefits (EOB). The insurer is responsible for the entire balance if an EOB has not been added. In the given example, an EOB is present, assigning $90 as the insurer's responsibility and $20 as the patient's responsibility.

Claims Payable to Insured Member, Patient, or Adjudicator Guarantor

When a claim is payable to the insured member, patient, or adjudicator guarantor, the Patient is automatically responsible for the full balance, independent of the EOB details. It's crucial to update the EOB to reflect "paid" once the patient has settled the invoice. For example, if the claim is adjusted to be payable to the patient, the updates must be recorded accordingly.