Who reviews health-related claims to determine whether charges are reasonable and medically necessary?

The claims examiner plays a crucial role in the health insurance process by reviewing health-related claims. Their primary responsibility is to evaluate whether the charges submitted for health services are reasonable and medically necessary according to the standards set by the insurance policy. Claims examiners scrutinize the details of the claims, including medical records, billing codes, and provider notes, to ensure that the services billed align with the diagnosis and treatment received by the patient. This assessment is essential for both the insurance company and the healthcare provider to ensure that resources are used appropriately and that patients receive necessary medical care without incurring unnecessary costs.

In contrast, healthcare providers focus on delivering medical services to patients and may not be involved in the administrative review of claims. Medical assistants primarily assist with clerical tasks and patient care in healthcare settings, and while they may help in the billing process, they are not responsible for reviewing the claims themselves. Health insurance specialists may be involved in various aspects of insurance claims, such as coding or processing, but it is specifically the claims examiner who has the definitive role of determining the reasonableness and medical necessity of charges within the context of a claim.