Claims Adjudication Process Research Paper

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
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 for determination of payment.

Determination of Payment, is the next step of this process and it is made based on the information received. At this point the claim may be paid, paid at reduced level or denied

Payment is the final step in the claims adjudication process, at this time if payment is deemed to be owed then the payer sends the payment to the provider with a remittance advice(RA) this is an explanation of decisions that were