The claim is be defined as a request or an appeal made by the entity or organization (on behalf of the provider) for proper reimbursement to the provider for the service rendered.
‘Claim Adjudication’ is defined as the claim submission and its subsequent settlement made by the insurance company. Claim adjudication ensures that all program requirements have been met (provider and facility in-network, a PCP referral has been made, notification requirements have been met, etc). Claims editing helps spot and correct problems faster before claims are sent to payers. Ensures accurate adjudication, prevents payment for unauthorized or inappropriate services, and manages coverage limitations by automatically administering all the provisions of each product line.
Fact-finding is the basic criterion on which the process of claim adjudication is built up. The various type of facts, which influence the claim adjudication are, Obtaining of facts, Recording of facts, Recording the absence of fact of any claim that has been filed for reimbursement.
The other factors, which contribute to claim adjudication are:
- Implementation of medical policy
- Post-Service Claims Edits
- Highly specific coverage criteria implemented on case-by-case basis
- Obtaining additional information from physician if necessary.
- Plan considers time and cost of implementing coverage restrictions
- Look at claims experience to gauge appropriateness of use
- Level of payment for new service
- Based on cost
- Based on comparable service
The standard forms often used by billing companies for submitting claims are:
Form 1: HCFA 1500
Form 2: UB 92
HCFA stands for health care financing administration. It consists of 33 blocks giving information about the patient, insurance, provider, and facility details. This form is mainly used for outpatient details.
UB stands for uniform billing. It consists of 86 blocks giving information about patient, insurance, provider, and employer details. This form is mainly used for inpatient details.
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