Claims Adjudication

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Claims Adjudication Process

Claims Adjudication Process

Claim adjudication is when a payer receives the claim, then issues an electronic response showing that it was a successful transmission. All claims then go through a process known as “adjudication”, this process is done in steps s listed

1. Initial processing

2. 2. Automated Review

3. 3. Manual Review

4. 4. Determination

5. 5. Payment

In the first step ,initial processing-all the claims information is checked by the payers claims processing system. All paper claims are date stamped and then the information is enters into the payers computer. This step of processing may lead to findings such as incorrect information, name of patient, plan information or service code may be incorrect, There may be missing codes or even if the patient is not the correct sex for a specific gender procedure code. These errors are common but any error will cause the claim to be rejected, If errors are found then the new instructions are sent to the provider to correct the information and then resubmit

Automated Review is the next step, this is when the” payers computer system apply edits that reflect their payment policies.” The automated review checks for information such as:

“1.Patient eligibility for benefits 6. Valid code linkages

2. Time limits for filing claims 7.Bundled Codes

3. Preauthorization and referral 8.Medical review

4. Duplicate dates of service 9.Utilization review

5.Noncovered services 10. Concurrent care”

Manual Review in this step the claim is reviewed by the claims examiner and an evaluation may be necessary and contacting the provider for an explanation may be necessary. If the claim is deemed acceptable it is then sent...
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