Claims Processing: What is Claims Adjudication?

This is a short summary of the claims adjudication process. For a comprehensive whitepaper outlining the entire process please complete the whitepaper download form below.

After a medical claim is submitted, the insurance company determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. The insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.

When an insurance company decides to reduce a payment to the provider, they have determined that the billed service level isn’t appropriate for the diagnosis or procedure codes. Therefore, it is important to ensure that all claims submitted for payment are coded accurately.

As soon as an insurance company receives a medical claim, they begin a thorough review. Sometimes even small errors such as a misspelled patient name may cause a claim to be rejected. This delay prevents you from receiving payment while corrections are made.

When claims are submitted electronically, the software can help prevent errors such as incomplete or inaccurate information before it is submitted for payment. This helps increase the speed at which you can be reimbursed for services.

Once claims are received by the insurance company, the review continues with detailed analysis of the insurance policy. Some claims are even checked manually by medical examiners who examine medical documentation to determine if procedures are medically necessary.

When the claim has passed through the review process, it can finally be paid. Having a claims processing partner, like Apex EDI, to prevent errors in claim submissions helps you get paid quickly. Contact Apex EDI to watch a free demonstration of our software today.