The purpose for this flow chart is to give a general description of the 5 steps in the adjudication process and how this process is related to the medical billing process.
Evaluation may be necessary
Returned to provider
& returned to provider
When a payer receives a medical claim, it goes through a five step process called adjudication where it is inspected and reviewed for processing, evaluation, or modifications if necessary.
Initial Processing: this step is where the claim is reviewed for errors such as incorrect names, identification numbers, or diagnostic codes. Claims with these types of mistakes are rejected and sent back to the provider with an explanation of corrections needed. If the claim is acceptable it is sent for an automated review.
Automated Review: this step is a review that is conducted by a computer program that applies edits to reflect the payer's payment policies. If an error is found the claim is suspended sent in for manual review. If the claim is acceptable it is sent for determination of payment.
Manual Review: in this step, the claim is reviewed by a claims examiner and if necessary, an evaluation of the information may be conducted by contacting the medical provider for explanation and input. If the claim is not acceptable it sent back to the provider with an explanation of corrections needed. If the claim is acceptable it is sent for determination of payment.
Determination: in this step, determination is made based on the information and the claim may be paid, denied, or paid at a reduced level based on the level of diagnosis.
Payment: in this step if payment is owed then the payer sends the payment to the provider with remittance advice (RA) which is an explanation of the decisions made.
The claims adjudication process is important to the...
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