Where Does Your Medical Claim Go After It Leaves Your Provider’s Office?
You just left your doctors office with a clean bill of health! But where does your medical claim go once it leaves the office? It is submitted to your insurance company for claims adjudication.
What is Claims Adjudication?
Claims Adjudication is the process of paying or denying claims that have been submitted after comparing them to the coverage or benefit qualifications. This process can be done manually or more commonly through a software program.
Claims Adjudication
The process of paying or denying claims that have been submitted after comparing them to the coverage or benefit qualifications.
Claims Adjudication Steps:
Step 1: Review claim for any mistakes.
The first thing that happens when a claim arrives at your insurance company is it will undergo a thorough review. This can be done manually but is often done with an adjudication software. The following details will be checked:
Proper spelling of patients name
Patient identification numbers
Sex of patient
Providers identity number
Any other basic information regarding the patient
If everything is accurate, the claim will be given a unique claim number. If the claim has errors such as listing the patient is male when it should say the patient is female, the claim will be rejected and will not go any further for review. Both the medical provider and the patient will get a letter stating why the claim was denied. To get this resolved the claim will then have to be resubmitted with the correct information.
Step 2: Undergo a Medical Review
Once the claim has been checked for any errors, it will then go through a medical review. The software will compare the medical claim to the insurance policy to determine what services will be covered by the insurance company and what will not be covered. This process is overseen by a certified nurse and
sometimes even a doctor depending on the criteria that was set in the insurance policy.
Step 3: Approve or deny claim
Once all the medical information has been reviewed, the claim will be approved, denied, or reduced. An explanation of benefits letter will be sent out to the patient explaining why the claim is being paid, denied, or reduced.
If a claim has been denied, a patient or medical provider may want to appeal the claim. This can be done by either making a phone call to the insurance company or submitting a requested form for reconsideration. It
is important to document all calls, letters, and forms if you are wanting to appeal a claim.
How can Imagenet Help?
Due to the high demand of medical claims that need to be processed every day, many insurance companies have now turned to companies like Imagenet to manage their medical claims. Imagenet’s Claims team is comprised of industry leading experts equipped with the knowledge and tools to help insurance companies handle medical claims and appeals.
To find out more about how Imagenet can handle your companies claims adjudication, contact us and one of our team members can answer any questions you may have.
