What does claims adjudication involve regarding a submitted claim?

Claims adjudication is a key process within the revenue cycle management framework that involves the evaluation of a submitted claim by an insurance payer. This process ensures that the claim is assessed for accuracy, appropriateness, and alignment with the patient's insurance benefits.

When a claim is submitted, the payer reviews it against several criteria, including whether the service was covered under the patient's plan, the medical necessity of the services rendered, any applicable payer edits, and the terms and conditions associated with the patient's benefits. This thorough verification helps to confirm that all aspects of the claim meet the required standards and the conditions of the insurance policy.

In contrast to claims adjudication, singular actions such as payment, alteration, or rejection do not encompass the full scope of activities involved. Payment, while important, is only one possible outcome of the adjudication process. Claim alteration may also occur, but it is not a standard function of adjudication itself, which focuses primarily on evaluation rather than modification. Similarly, rejection of claims can be a possible result of adjudication, but it does not define what claims adjudication entails as a whole; it involves both assessing eligibility and making a final determination on payment.