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Claims Adjudication

What is claims adjudication?

Claims adjudication is a long and complex process that is used by a payor to evaluate a medical claim. They use it to determine how much will be reimbursed to a healthcare provider for administering care services.

The payor reviews the claim for relevancy and ensures there are no errors in the patient’s personal details and no omissions. It is then checked for appropriate and accurate medical codes such as the Healthcare Common Procedure Coding System (HCPCS) and the Current Procedural Terminology (CPT).  Claims are sometimes checked by a medical examiner to determine if the procedures being claimed for were necessary and valid.

Once they have evaluated the claim, they have three options:

  1. Pay the claim in full
  2. Reduce the amount paid out
  3. Deny the claim

If a claim is denied, an appeal can be carried out. Once the errors have been resolved, the claim can be submitted for review again. This extends the processing time of the claim and delays the reimbursement.

You can find out more about the medical claims process here.

Why is the claims adjudication process important in healthcare?

This process is important as it ensures that medical claims are accurate, valid, and necessary. These claims are also important sources of data for healthcare organizations to trace referral patterns and accelerate their go-to-marketing strategy.