Medical Claim

Medical claims are medical bills submitted to health insurance carriers and other insurance providers for services rendered to patients by providers of care. Medical claims rely on diagnosis and procedure codes ICD-9/ICD-10 and CPT/HCPCS, respectively, to describe the patient’s illness burden and services rendered. Encounters are medical claims where the requested payment from the health insurance carrier or insurance provider is zero dollars. Encounters are used to describe or report services that were rendered but whose payment is typically covered by capitation or other bundled or episode-based arrangements in which no payment is required for the services documented on the encounter.