There are five steps in the claims adjudication process. Initial processing is the first step. Initial processing finds any problems such as; name, identification number, or the plan of service code is wrong. This has to be fixed before anything further can happen. Automated review is a system that checks for ten things that maybe reflected on their payment policy. The review checks for the following; patient’s time limits for filing claims, referral forms, preauthorization, and the patient’s eligibility benefits, bundled codes, non-covered services, medical review, concurrent care, utilization review, and duplicate dates of service. The third step is manual review. Manual review happens if problems occur from the previous review; the claim is suspended and set aside for development. This step is usually followed to review the medical necessity of an unlisted procedure. Determination is the fourth important step. This is where the decision is made to pay it, deny it, or to pay it at a reduced level. If the service falls within normal standings, it will be paid. If it is not reimbursable, the item on the claim is denied. If the examiner determines that the service was at too high a level for the diagnosis, a lower-level code is assigned. The last step is making a payment. If payment is due, the payer sends it to the provider along with a transaction that explains the payment decisions to the provider. Adjudication process is an important process because it checks for any errors that may have been missed on the claim, this will allow for a more accurate process and things will be done in a timely manner.
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