This article expresses the system of payment to the healthcare providers by claim adjudication. After submission of a medical claim, the insurance company takes the responsibility of providing payment to workers and this system is called "claim adjudication". The insurance company has the authority to fully pay the claim, to oppose the claim or to reduce the amount to be submitted. Claim adjudication can be a quick service when a clean claim is encountered. “Clean” in this line indicates that all the information printed on the claim is accurate and lies within the patient healthcare policy.
The claim adjudication process has upgraded recently because of advancements in software technology. The collection of a large amount of data and its verification is the great achievement over the "hands and eyes" on every claim in the past. The software Medicare and Medicaid are error-free and highly precise for verification of submitted claims. Both of this software have specific rules regarding the payment of services provided.
Let's have a detailed look at the process of medical adjudication. The review process has been done by insurance organizations after receiving the claim. Claims are lineup through the verification process. The software continues to check the all information regarding the date of service and hospital visiting and admitting schedule. If the information provided is not attached to the id number, the triggering of the rejection step may occur.
A referral number is provided by the insurance company to each claim and negligence of providing referral number cans leads to claim rejection. Indication of small errors like misspelled patient name, alteration in their social security number leads to rejection of claim immediately.so it is important to make sure that all claims to be submitted are coded accurately. Corrections are made electronically, so this mistake can lead to delaying payment.
When the higher authorities in insurance companies decide to reduce the payment of providers, there might be an occurrence of mistakes in medical coding. It mostly happens if the billing in a claim is not legal according to the diagnosis, prognosis, and coding procedures.
The most vital information of the claim is procedure code (CPT) and the diagnosis code (ICD-9). Matching of the procedure with the diagnostic code is done by software provided and remittance advice is generated after going through the process of medical review. And claims can finally be paid after passing the medical review by the physicians. Claims processing partner can help you to get paid immediately.