Claims Adjudication Process

Claims Adjudication Process

There are five steps in the claims adjudication process; they are initial processing, automated review, manual review, determination, and payment. Initial processing is the first step in the claims adjudication process. The purpose for initial processing is to find any problems such as patient name, plan identification number, place of service code, or diagnosis code that may be wrong or missing. This has to be fixed before going any further in this process. The second step is automated review, which checks for things that may be reflected on their patient eligibility for benefits, time limits for filing claims, preauthorization and/or referrals, duplicate dates of service, noncovered services, valid code linkage, bundled codes, medical review, utilization review, and concurrent care. The third step is manual review, which helps finds problem that happened from automated review; the claim is then suspended and then set aside for more information to be gathered to adjudicate a claim. This step is usually followed in order to review the medical necessity of an unlisted procedure. The fourth step is determination, its purpose is to make a decision on whether to pay, deny, or pay at a reduced level of benefits. If the service falls within normal guidelines then it will be paid, if it is not reimbursable then the item is denied on the claim, and if the examiner determines that the service was at too high a level for the diagnosis, then a lower level code is assigned. The fifth step is payment, which If payment is due the payer sends it to the provider along with a remittance advice (RA) or electronic remittance advice (ERA), which explains the payment decisions to the provider. Claims adjudication process is an important process in the medical billing process because it checks for any errors that may have been missed, that because a claim to be denied, rejected, or adjusted, which will allow for a more accurate claim to be submitted and...