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Claims Adjudication Process

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Claims Adjudication Process

The claims adjudication process has five steps. The steps are initial processing, automated review, manual review, determination, and payment. In the initial processing paper claims and any paper attachments are stamped with the date and entered into the payer’s computer system, by either data-entry personnel or by scanning them into the system. This process might find problems such as the patient’s name, plan identification number or plan or service code is wrong. The diagnosis code may be incorrect for the date of service or it might be missing altogether, or the gender-specific procedure code is not correct for the patient’s gender. Any claims that have mistakes are rejected. The provider is instructed to correct the errors and re-bill the service. The claim goes through the automated review after the initial process. This review looks at the patient’s time limits for filing claims, referral forms, preauthorization, and the patient’s eligibility benefits. Bundled codes, non-covered services, medical review, concurrent care, utilization review, and duplicate dates of services are also checked for during the automated review. The claim is stopped if problems are found, and the claim is set aside for manual review. During manual review, more information may need to be provided so that the claim process can be finished. An examiner receives the claim, and they can ask the provider for any additional information that is necessary for processing the claim. Once every mistake has been fixed, the claim is sent for the determination process. In the determination process, the decision is made for payment, denial, or payment at a reduced rate. Once this has happened, the payment (if applicable) is sent to the service provider, along with an explanation of the decisions of payment. The adjudication process is important because it catches any mistakes that might have been processed on the claim.

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