1. Resource: Appendix A, pp. 449–477 in Ch. 14 of Medical Insurance, and Microsoft® Help website
2. Refer to Ch. 14 of Medical Insurance and previous assignments from that chapter as a resource. Visit the Microsoft® Help link for assistance with questions related to creating a flow chart in Microsoft® Word at: http://support.microsoft.com/
3. Create a flow chart using Microsoft® Word illustrating the five steps of the claims adjudication process from the time of initial processing through final payment. Include a brief 250- to 300-word explanation for the following:
· Identify the purpose for each step in claim adjudication process.
· Explain the relationship between each of the different steps.
· Provide a one-sentence summary describing how claims adjudication is important to the medical billing process.
The claims adjudication process has five steps. These steps are initial process, automated review, manual review, determination, and payment. In the initial process, problems such as the patient’s name, plan of service code, or the plan identification number may be wrong. The diagnosis code may be incorrect for the date of service or might be missing altogether, or it might be that a reported gender-specific code and the patient’s gender do not match up. Any claims that have mistaken are rejected. The provider is instructed by the payer to correct the errors and submit the claim again. The claim goes through the automated review after the initial process. This reviews 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 service 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 this review, more information may need to be provided so that the claim process can be finished. An examiner receives the claim, and this person can ask the provider for any additional information necessary for processing the claim. Once every mistake has been fixed, the claim is sent for the determination process, when 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. This adjudication process is important because it catches any mistakes that might have been processed on the claim.