Introduction
The adjudication process is also sometimes referred to as the claims management process, but it is important to note that they are different processes. In this article, we will explore what the difference between them is, what steps you can expect when you submit a claim through your insurance company and how they decide on whether or not they should pay out compensation for their clients.
Submitting a Claim
● The provider submits a claim to the payer electronically by using an appropriate electronic data interchange (EDI) format.
● The provider submits a claim via mail, fax, phone call, email, or patient portal from their office computer to the payer’s designated address or phone number for the submission of claims and/or remittance advice messages.
Claims Processing
Claims processing is the process of evaluating and processing claims submitted by providers. Claims processing starts with the submission of a claim to a payer, who then decides whether or not to pay the claim. This decision process can be either automatic or manual, depending on whether or not a CPT code has been assigned by CMS.
If you are unfamiliar with CPT codes and how they work in conjunction with claims processing services, see our previous article on this topic: What Are CPT Codes? The Complete Guide To Understanding Medicare Billing Procedures And Claim Adjudication Procedure For Providers
Claims Adjudication
Claims Adjudication is the process by which a health plan or government program reviews and pays a claim. The Claims Adjudication Workflow consists of six main steps:
● Receipt of Claim – The first step in the claims adjudication process is receiving the claim from providers (e.g., doctors, hospitals). Claims can be submitted electronically, through hard copy, or via fax; however, not all providers submit their claims electronically as there are some that still prefer to submit them manually. Some also choose to submit their claims directly to payers rather than using intermediaries such as clearinghouses or billing services.
● Validation – Once received by payers/carriers/hospitals etc., these entities will verify whether information on them (e.g., patient’s name) is correct before proceeding further into processing them further down in this workflow diagram above where they will determine whether these documents should be paid out based on whether they meet certain criteria set up ahead of time within their policies regarding coverage types (i..e coinsurance deductible), etc.
3 . Review & Approval – Next up after validation comes review & approval where case managers decide if something needs additional clarification before making any decisions about what kind of action needs to be taken next based on earlier validation results coming back positive or negative depending on the type(s) being processed here too!
Post Adjudication Review
After the healthcare provider submits a claim to the payer, it will be reviewed by the payer’s adjudication team. The adjudication team is responsible for ensuring that all of the necessary documentation has been provided and that all information is accurate. If any discrepancies are found in a claim, it may be denied.
If you disagree with your insurance company’s denial of payment or its determination of your reimbursement rate, you can request an appeal by submitting a written explanation as to why they should reconsider their decision. Your explanation should provide any missing documentation or explanations needed to resolve any discrepancies found during their review process. In some cases, an appeals officer may hold a hearing before issuing their final decision on whether or not to overturn the initial denial of payment request.
Denied Claims Review
If your claim is denied, you may have an opportunity to provide additional information about your claim prior to adjudication. This is called “Claims Review” and works similarly to the Provider Portal. The payer will send you a notification that your claim has been denied and give instructions on how to proceed. Providers should follow these instructions carefully as each Payer may require different documents or processes for completing Claims Review.
If a provider disagrees with a decision made by their payer during the claims review process, they may appeal it through an independent third party: OIG (Office Inspector General) or TPA (Third Party Administrator). If both parties cannot come to an agreement, then they have the right to contact CMS directly by filing an appeal through RAC (Reasonable Adjustment Committee).
Once claims are reviewed and approved by CMS/TPA/OIG or RAC then providers should receive a payment within 14 calendar days of submission except if otherwise stated in contract language between themselves with their respective payers
Takeaway In this section, we describe the claim adjudication process and review processes for both payers (denied claims appeals) and providers (post-adjudication reviews).
Adjudication is a thorough review workflow that involves both payers and providers. It is the final step in the claims processing process, where all parties involved with a claim come together to complete their respective parts of the transaction. The result of adjudication may be paid, denied, or pending.
The adjudicated claim can originate from various sources:
● A Payer-initiated review (e.g., audit)
● A Provider-initiated review (e.g., self-audit)
● Resubmissions from prior adjudication attempts
The process of adjudicating claims can be complex, with many different actors involved. However, the key takeaway is that the end result should always be fair and equitable for all parties involved in a claim. In addition to being fair and equitable, this process must also be efficient so that providers can get paid as quickly as possible while still ensuring quality outcomes for patients.
