Claims Adjudication Process

Claims Adjudication Process

Claims Adjudication: After the medical claims submitted, insurance company will evaluate the financial responsibility for the reimbursement to the provider. This process is called Claims Adjudication. The insurance company may decide to pay the full amount of the claim, reject, or may reduce the amount paid 

to the provider.

If an insurance company decided to reduce the payment to the provider, it has determined that the level of service billed is not sufficient for diagnostic or procedure codes. It is also necessary to verify that all claims submitted for reimbursement are coded correctly.

So soon as an insurance company accepts a medical claim, they done through the review is initiated. Often even minor mistakes, such as the misname of the patient, can lead to a denial of the claim. This delay prevents you from getting reimbursement while the corrections are being made.

When claims are submitted electronically, the software may help to avoid errors, such as incorrect or incomplete information before submitted for payment. This will get increase the level at which you will be paid for services.

Once claims are received by the insurance company, the examination shall proceed with a thorough examination of the insurance policy. Some claims are also reviewed manually by medical examiners who examine medical documents to decide if treatments are medically necessary.

Once the claim has gone through the approval process, it will be finally get paid towards the claim.