Hcr230 Adjudication Flow Chart Week 9

CLAIMS ADJUDICATION PROCESS

HCR230

March 3, 2011

PURPOSE:

Initial Processing is when each claim’s data elements are checked by the payer. This is done by the front-end claims processing system. All paper claims and attachments are entered into the payer’s computer system and date stamped. This is done by either a person or by using a scanning system. Further processing is when any problems or errors are found within the claim. If they are wrong the claim is rejected. Instructions are given to the provider on what is wrong and needs to be fixed. The provider then needs to resubmit for initial processing again with a new clean claim.

Automated Review is when the payer’s computer system applies edits that show their payment policies. There are several things the automated review checks for. Patient eligibility, duplicate dates of service, and valid code linkages are just a few of the things that the automated review checks for.

Manual Review is a review that results from problems found in the automated review. If this happens the claim is suspended and set aside for development. This means that the payer indicates that more information is needed in order to finish the claims process. These claims are sent to a claims examiner, who then reviews the claim. The claims examiner may ask the provider for additional information.

Determination is when the payer makes a payment determination for each line of the claim. The decisions are whether to pay, deny, or pay the claim at a reduced level. The determination decision is based on whether the claim was within guidelines, not reimbursable, or the service was charged at too high of a rate.

Payments are due when the payer deems the claim to be within all of the correct guidelines. The payer will send payment along with a remittance advice (RA) or an electronic remittance advice (ERA). These are what explains the payment decisions to the provider. Payment can be sent in paper form or...