Health insurance companies use a variety of methods to verify claims and ensure accurate reimbursement.

• Direct Billing Claims: The network provider submits claims either directly to the insurer or via third party administrator (TPA). Verification involves eligibility checks, medical documentation, and procedure validation through insurance software & TPA process as per policy terms and conditions.
• Reimbursement Claims: The insurer checks documents submitted by the policyholder, reviews service codes as per the coverage and medical necessities and processes the claim accordingly as per policy terms and conditions.

In contrast, for reimbursement claims where the patient pays out-of-pocket first, the insurance company verifies the details directly with the customer. They review the medical records, codes, and charges submitted by the patient to confirm the services were medically necessary and billed correctly.