Claim Adjudication Services We Offer
Services
- Determination of Claims Value
- EOBs
- Investigation of Claims for Duplicates
- Adjudication of Insurance Benefits
- Data Retrieval from Unprocessed Claims
- Data Accuracy Verification Using the Claims Adjudicating Engine
- Examination of the Patient Data and Diagnostic Code
- Assessment of Healthcare Service Provider Information
- Comprehensive Claim Validation to Identify Fraud
- Fulfilment of Judged Liabilities
- Claims Adjudicating Entitlement
- Computing Claims Amount
- Coding, Bundling, And Review
- Adjudication Based on Benefit-Based Determination
Types of Claims We Adjudicate
Adjudicate Claim Types
- HCFA 1500 / CMS 1500
- UB92/UB04
- Enrollment Forms Processing (EFP)
- Vision Forms
- Pends / Correspondence
- Dental Claims
- Remittance Processing Services
What makes us Different ?
First Review of Claims Processing
Since all claims with basic errors and omissions can be returned at this point, we think the initial step in the claims review process is also the most crucial because it reduces the processing load later on. In this stage, we look for the following things:
- Misspellings and other errors in patient names
- Inaccurate plan numbers, member IDs, or identity numbers
- Missing or incorrect diagnostic code
- Incorrect service dates
- Incorrect service codes
- Patient’s gender mismatch
Automated Review of Claims
An extensive review of the claims is conducted at this step in order to obtain particular information about the payer’s payment rules. Since many improper payouts can be halted at this point itself, it is crucial to take this step. Problems found at this stage include:
Submitting several claims– Claims that have already been filed for the same date, method, or person are marked.
Unnecessary Assistance Provided– Sometimes claims are made for unnecessary and costly services that may have been easily avoided with less expensive options or faster procedures.
Erroneous procedure and diagnosis codes– Sometimes diagnostic and procedure codes are listed incorrectly in the claims; if you catch this, it might save you more headaches.
Invalid Pre-authorization – Periodically, the information provided during pre-authorization does not match the diagnosis, operation, or procedure that was carried out.
Timely Filing Issue – The processing of your claim is halted if the medical claim is filed after the time specified by your insurance policy.
Patient Eligibility – The claim may be denied if the patient is not qualified to submit the application because of a claim mismatch, unpaid bills, etc.
Complete Manual Review of Claims
Our skilled group of medical and healthcare claims examiners begins reviewing the claims at this point to look for any additional mismatches. To verify the veracity of the claim, they may also request copies of pertinent medical records and other records. When claims are filed for non-listed operations and the medical necessity of those procedures needs to be verified, this step is vitally important.
Payment Determination
Irevenuebilling primarily employs three kind of payment determinations, which are as follows:
Paid – When a healthcare claim is deemed paid, the insurance payer decides whether to repay the claim.
Denied – When a healthcare claim is deemed to be refused, the payer determines that the claim is not eligible for reimbursement.
Reduced – If the diagnosis indicates that the invoiced service level is excessively high, the procedure code may be downcoded.
Payment
The last step is submitting the payment to the payer’s designated office, which is referred to as the payment explanation. This contains details like the justifications for the payment decrease, rejection, adjustment, etc. Additionally, it contains details like the adjudication date, covered amount, allowed amount, paid amount, approved amount, and patient responsibility amount.
Our thorough 5-step verification procedure makes sure that all of your data is validated, enabling the correct processing of false claims. For our clients in the US and around the world, we cover a range of healthcare claim types, including:- HCFA claims 1500 / CMS1500
- UB92 (Single / Multi / Attachment / COB)
- MEDICAID
- MEDICARE
- UB04
- Superbills
The process We Follow for Claim Adjudication
The adjudication of medical and healthcare claims is a demanding procedure that necessitates in-depth familiarity with cost-cutting strategies to combat fraud. If you lack a competent workforce to quickly and accurately decide claims, this task becomes more difficult. The majority of your worries are resolved when you outsource claims adjudication to Irevenuebilling because we have experts in both manual and computerised claims adjudication. The following describes our claims adjudication procedure: