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Outpatient Claim

What is an outpatient claim?

An outpatient claim is a medical bill submitted for ambulatory services and other services provided for outpatients.

The services included in an outpatient claim generally consist of physician fees and the costs of tests and treatments. Unlike inpatient care, the outpatient claim does not include the cost of a hospital stay.

Examples of outpatient care, which will be issued an outpatient claim, include:

  • Diagnosis (e.g., imaging scans, lab tests)
  • Wellness and prevention
  • Rehabilitation
  • Treatment (e.g., chemotherapy, some surgeries)

Why are outpatient claims important for healthcare?

Outpatient claims are medical bills containing all services and care the patient received from a facility without partaking in an overnight stay. The outpatient’s insurance provider then assesses the medical codes to determine the reimbursement amount for the provider for their services. Based on this, outpatient claims are a crucial step for compensating facilities services they provide.

Those with Medicare Part B cover many diagnostic and treatment services received as an outpatient from a Medicare-participating hospital. The hospital will file the claim with Medicare, and then Medicare will pay them their reimbursement directly.