Claim Adjudication Process In HealthCare

Praveen Singh         No comments




What Is Adjudication ?

Every claim submitted undergoes a process made up of procedures designed to judge how it should be paid - or not - known as adjudication. Each filed claim undergoes the Adjudication process, this step is important to determine the status of the claims. The status may go to Pend status if there is any problem in the claim. In that case, the Claim don't get processed, it goes back to the team for the examination. Millions of claims get processed each day by insurance companies, so, it's not done manually. There are a lot of  Claim Processing Softwares or Tools are available in the market. And, the success rate of all these tools is different. Once the Claim goes into the Pend status, it gets checked manually. Once the error gets corrected, it gets filed again and it has to go through the Adjudication process again.

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Claim Adjudication 

Claim Adjudication is not the simple process. There are a lot of steps involved in it. Different claim Processing Softwares has different logic to adjudicate the claims but there are certain steps and all Claim processing tools have to operate in this order only.

Claim Adjudication Step 1 :

The first step is to determine the Member and Provider Status. A Member is someone who receives the service and the Provider is someone who provides the service. So, once the Claim gets filed , the first step is to ensure the validity of the Members and Providers. If the Member is not enrolled in the Plan then this Claim will get rejected.Also, the Plan should be active. If the Plan gets termed and the there is no question of filing the Claim. All these variables get validated and checked with the Software Processing software.


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Claim Adjudication Step 2 

Each plan has benefit packages for the Subscribers of the plan. The Member will get benefitted only for the benefit packages covered under his plan. If the rendered service is out of the Member's package, the Claim won't get paid. So, in the 2nd step, the performed HealthCare Service is authorized.The health plans pay benefits only for healthcare services that are medically necessary and appropriate It reduces a plan’s medical malpractice liability : A plan can be liable for the negligent acts of its employees or medical staff and in some cases contracted providers.So, it must take measures to ensure that the care they provide is appropriate.

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Claim Adjudication Step 3

Clinical edits are typically supplied by an external vendor whose software specializes in healthcare codes and is integrated with the health plan’s claims system. Also, for some plan, there may be some referral requirements, all these requirements must be met before being the Claim being paid.

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Claim Adjudication Step 4

The last step is to determine the Amount, that will get paid to the service provider. There are many factors involved in this also as Deductible, Copayment, Coinsurance. Based on all these factors, the amount gets calculated and paid to the Providers.This step also inspects the possibility of the fraud.If the information is not complete for the provided service then the Claim gets examined and in a case of any kind of fraud, it doesn't get paid.

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Published by Praveen Singh

A blogger by passion.You can find me tucked in my bed and blogging on weekends when not roaming around. Besides blogging, I love music and you can find my songs on my fb page:PraveenUnplugged
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