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What You Should Know About the Claim Adjudication Process

When dealing with insurance claims, you’re going to put up with a long and arduous process. Most insurance companies follow certain steps to make sure they make the right adjudication decisions. But, from the way claims are reviewed to the way claimants are paid or denied, this entire process can be very frustrating for people, like you, who’ve been hurt in some way. Yet, it’s still important that you understand the entire claim adjudication process and what your options are to ensure your rights and interests are protected throughout the way. 

Thus, if you’re making a claim for a dog attack or other accidents, like car or slip and fall accidents, here are some common things that you should know about the process:

Your Claim Will Be Checked For Errors And Omissions

To get started with the claim adjudication process, the adjuster will review the documents that you submitted and check it for errors and omissions. This step is commonly called the initial processing review. At this stage, the adjuster will see to it that your application form is free from any mistakes that would affect your chances of getting an approved claim. 

The following are the common problems identified during this step:

  • Incorrect patient name
  • Wrong subscriber identification number
  • Wrong place of service code
  • Invalid or missing diagnosis code

Checking for claim errors and omissions is done manually in a claim adjudication process. Hence, to avoid this time-consuming procedure, insurance companies are starting to adopt the process of auto-adjudication to automate the identification of errors and make this step more efficient for you and the insurance adjuster. 

More Detailed Items Will Be Checked Based On The Insurance Policy

Apart from the errors in the application form, the insurance adjuster will check more detailed items based on your insurance policy to determine whether your claim is approved or denied. This step is called the automatic review. 

Under this stage, the following problems are taken into account:

  • The insurance coverage is no longer active.
  • The diagnosis or procedure conducted doesn’t match the information submitted. 
  • The submitted claim is a duplicate of another claim. 
  • The diagnosis or procedure conducted is invalid.
  • The procedure or services performed to the patient isn’t necessary at all. 

Your Claim Form Is Compared With Medical Documentation

Once the more detailed items are checked, the next step would be the manual review. Under this process, your claim will be examined by the medical claim examiners by comparing your claim with the medical documentation. This is to make sure that all information provided in the claim form matches the information lodged in your medical records. 

And, to streamline this procedure, many insurance companies and healthcare providers are taking advantage of EDI clearinghouse as a technological solution designed for a seamless data exchange between them and other networks. This technology allows them to access important medical data necessary in making sound adjudication decisions. 

The Insurance Company Determines How Much Payment You’re Entitled For

After the manual review, the next step in the claim adjudication process is the payment determination. Primarily, payment determination is the process of determining how much a person is legally entitled to receive as payment for a medical condition or injury. The determination of the total compensation due to an injured person is accomplished by examining all relevant factors to find out if the injury was caused by negligence or another breach of the patient’s responsibility in the claim procedure.

Moreover, payment determination in the claim adjudication process involves several steps and factors that must be considered. The criteria may include the following:

  • Duration of a medical treatment, as well as any other losses or damages that a patient has suffered after they had undergone a treatment that the healthcare professional deemed necessary
  • Consideration of the compensation that a patient must have in order to live a happy life
  • Severity of a patient’s injuries and the loss of any physical capability

Your Claim Must Be Filed On Time To Avoid Unnecessary Costs And Delays

Just like other insurance processes, the claim adjudication process can be a time-consuming undertaking. If you file your claim too late, then, it may cost you more money and be more difficult to obtain a claim adjustment. In addition to this, you may not get any claim adjuster assigned to your case, which means that you’ll not get any help from the adjuster until the claim has been processed. All of these factors mean that you should make your claim submission date as early as possible and submit all necessary papers on time. 

Final Words

As mentioned, the claim adjudication process is an important step in the processing of an insurance claim. The claims adjuster will review the policy documents and other relevant information to make sure you’re covered by the insurance policy. 

Therefore, if you’re filing a claim with an insurance company, keep this information in mind so you’ll know what to expect before you can get started. This article may give you an idea on how the claim adjustment process can work best for you.