What is the difference between hospital claims processing and professional (provider and/or CMS 1500) claims processing?

Hospital claims processing and professional (provider and/or CMS 1500) claims processing are two distinct processes in the healthcare industry.

1. Hospital Claims Processing:
- Hospital claims processing refers to the handling of claims submitted by hospitals for reimbursement of services provided to patients.
- Hospital claims typically involve a wide range of procedures, tests, medications, and medical supplies used during a patient's stay in the hospital.
- These claims may include hospital stays, surgeries, emergency room visits, diagnostic tests, medications, and other services provided by the hospital.
- Hospital claims processing involves reviewing the documentation, coding the services provided, and submitting the claims to insurance companies or government payers for reimbursement.

2. Professional (Provider and/or CMS 1500) Claims Processing:
- Professional claims processing refers to the handling of claims submitted by individual healthcare providers, such as physicians, therapists, and other healthcare professionals.
- Professional claims are typically submitted on the CMS 1500 form, which is a standard claim form used for reimbursement in the United States.
- These claims may include services such as office visits, consultations, surgical procedures, diagnostic tests, therapies, and other healthcare services provided by individual healthcare professionals.
- Professional claims processing involves reviewing the documentation, coding the services provided, and submitting the claims to insurance companies or government payers for reimbursement.

In summary, the main difference between hospital claims processing and professional claims processing lies in the types of services included in the claims and the entities submitting the claims. Hospital claims involve a broader range of services provided by hospitals, whereas professional claims involve services provided by individual healthcare professionals.