BC Advantage - 2017 Issue 6
CLAIM ADJUDICATION PROCESS
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Article Overview
This article explains the claim adjudication workflow used by payers to evaluate submitted claims and determine whether they can be reimbursed. It is aimed at billing, coding, and revenue cycle readers who want a general understanding of claim review stages, common claim errors, and how payer review processes affect payment outcomes.
Why This Topic Matters
Understanding adjudication helps coding and billing staff anticipate why claims may be delayed, pended, denied, or sent for further review. It also highlights the importance of accurate claim data, documentation support, and payer policy compliance.
Article Sections
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Overview of claim adjudication
Introduces the claim adjudication process and describes it as a payer workflow for evaluating claims before reimbursement.
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Front-end edits and common claim errors
Covers automated edits used to screen claims and the general categories of problems that can be identified during that review.
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Claims examiner review and resubmission
Describes what happens when claims do not pass initial edits and may require correction or further payer review.
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Medical review and reimbursement decision
Summarizes the later review stage in which claims are evaluated for coverage, policy compliance, and final payment approval.
What You Will Learn
- How payers typically process claims after submission
- What kinds of issues are commonly identified during automated claim review
- How claims may move from edit review to human review
- How payer policy and documentation affect reimbursement outcomes
Who Should Read This
- Medical coders
- Medical billers
- Revenue cycle staff
- Practice administrators
- Healthcare claims staff
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