Claims Adjudication

Han Digital Solution

2 - 6 years

2 - 5 Lacs

kochi thrissur kozhikode thiruvananthapuram

Posted:19 hours ago| Platform:

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Skills Required

basic usage claims hcpcs compliance claims adjudication manual

Work Mode

Work from Office

Job Type

Full Time

Job Description

Claims adjudication is the process insurance companies use to evaluate a medical claim and determine if it should be paid, partially paid, or denied . It involves verifying the claim for accuracy, checking patient and provider eligibility against the policy, and reviewing for compliance with plan rules, often resulting in an approval, adjustment, or denial. The goal is to ensure accurate payment to the provider while staying within the terms of the insurance policy.

The claims adjudication process

Initial review
: The insurer checks for basic information like patient details, diagnosis codes, and treatment location. Errors or missing information at this stage can lead to a rejection.
Automatic review
: The claim is scanned for more complex criteria, such as checking for prior authorization and ensuring the procedure codes (like CPT or HCPCS) are appropriate and accurate.
Manual review
: Some claims may require a deeper review by a medical examiner to determine if the services were medically necessary and valid.
Final decision
: Based on the review, the insurer decides to approve the claim, adjust the amount to be paid, or deny it entirely.
Payment and Explanation
: If the claim is approved or adjusted, the insurer issues a payment, often accompanied by a remittance advice or explanation of payment that details the amounts paid and the reasons for any adjustments or denials.

Goals of claims adjudication

Accuracy
: To apply the correct benefits and pricing based on the members policy.
Timeliness
: To process claims and issue payments within required timeframes, such as those mandated by state or federal regulations.
Efficiency
: To automate the processing of the highest number of claims possible to reduce overhead costs and potential penalties.

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Claims Adjudication