Everything You Need To Know About Medical Claims Adjudication

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Patient health insurance claim form in doctor or nurse hands for medicare coverage and medical treatment from illness, accident injury and admitted in hospital ward

“Claims adjudication” refers to the insurance claim processing in general. Claims adjudication may be completed manually or automatically, though both ways must be managed in a detailed and finite manner. Doing so ensures that all medical bills are approved or rejected based upon the health insurance company that’s accepted by each medical location. Hence, all medical files related must be kept properly to avoid further complications, such as the insurance company denying your claim.

Careful steps exist within the adjudication process – from receiving a claim from an insured person to using software for claims processing

Difference Between Manual and Automatic Claims Adjudication

Historically, medical claims adjudication was most commonly processed manually by insurance professionals. Even with technology now automating many different processes, this is still the requirement of some health insurance companies. So, some simple definitions of manual and auto-adjudication exist in similar manners:

  • Manual claims adjudication: In manually adjudicated claims, everything is recorded on paper forms, which is then submitted to the insurance company. 

While this doesn’t necessarily match the needs of the patients or the physicians very efficiently, there’s the potential that manual claims adjudication is much more detailed for those difficult situations that include questions on both sides of the case. 

  • Auto-adjudication: When using software or online platforms for claims adjudication, auto-adjudication offers a lot of benefits for insurance companies. Coming from the automation of software and web-based subscriptions, the time processes in manual adjudication are reduced. 

There’s much to consider with both of these. And there are still many reasons why auto-adjudication is much more efficient and productive than manual claims adjudication. However, there’s also much more to gain with the detailed and in-depth work that comes from manual claims adjudication. 

The Final Steps of Claims Adjudication

Some of the most important things to keep in mind about claims adjudication include your potential to keep track of all approved, rejected, and partially paid claims by your insurance company. Additionally, you must also have records of the responses that come to your claims. This way, when there’s some kind of dispute with your insurance company, you’re going to be well-equipped with the necessary files. That being said, you have then the right to file an appeal if you don’t agree with the insurance company’s decision, especially when you know that you have the files or records that warrants approval from the insurance company. 

It is most important to consider the ability to streamline both manual and automatic claims adjudication with tools and software such as Smart Data Solutions. With the ability to streamline all manual and auto-adjudicated claims, the work of those who process claims in these systems provides the highest quality and complete solutions. 

Closing The Claims Adjudication Process

No matter the type of claims adjudication, insurance companies send reports to the filers. The outcome of the claim is included, most importantly whether it was denied or approved, or even more so if there was a partial payment made. 

The status of annual insurance claims is often included as well, given the amount of insurance available for the rest of the year to cover claims. Sometimes, this information is defined as a remittance advice, starting with a statement of denial or approval for this claim, including the details of claim denial and how it could be explained by regional laws. 

Additional explanations are included with the claim sent to filers. You may have many details to learn about each claim, along with helpful information about your policy as a whole. Some of these details help with the future of your insurance and even more about your policy renewal every year. Even many of these claim result letters are not the greatest answer to tell you what you have left for the remainder of the year and what you qualify for in the claims you may still need to make.

Summary

So, at this point, everyone is informed of what is approved or not, and payments are sent to the providers in the event that the claims are approved. No matter what the result of the claim may be, it’s important that all details of the approval or denial, complete or partial, is explained in detail to everyone involved. Even more, it is important to have the claim fully explained along with the ability of the filer to resubmit an appeal if needed. 

Basically, the most important person to understand an insurance claim is the one who files the claim, knowing everything from the policy to what is being claimed and the ability to appeal any rejections.

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