Explain The Adjudication Process

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Adjudication Process Tawanza D. Cross Southern Technical College Professor JD Dickey Adjudication Process Insurance companies most important job is the adjudication process of medical claims which have several very important steps to ensure a timely processing manner, free of errors, correct codes, review if possibly needed, then the determination and finally the payment is rendered to the persons whom the maximum reimbursement rendered the service provider. The initial processing requires a lot of detail and attention by checking the claim’s data elements. When errors occur the claim can be rejected which adds on life the claim. This process verifies pertinent information for each claim, such as patient’s name, correct plan identification, diagnosis codes and even gender for gender specific procedures. An automated reviewed mostly initiated by the computers software program checks elements claims information that was provided or attached to the claim at the time of submission. The implementation of (CCI) Correct Coding Initiative in which Medicare subjects their claims to. Helps catch errors before the claim is processed. This process gathers EOB, the limitations for filing claims from the day of service and/or preauthorization and referrals. Acknowledgment of services not covered, correct code linkage, and that correct …show more content…

Which happens when problems arose in the automated review, first the claim is suspended and the goes through a development process to figure out what the problem is. Clinical documentation is viable during this process. The examiner looks for where the service took place, whether the treatments or services were appropriate, logical and their looking to see if the services were accurate. If any there is any insufficient medical reports or documentation, they seek the help of the medical professionals to help determine how the error

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