Medical Claims Adjudication

Medical insurances is a huge part of our day-to-day life but have you ever paid attention to the inside workings of how a claim is settled. Right from the issuance of the claim, to the verification and the eventual payout, the procedure requires utmost patience and full attention of the individuals processing these claims.

Claims processing is usually a five-step procedure that goes something like this:

  • The Initial Processing Review: In this process, the claims are usually checked for simple errors or any missing items that can be rectified immediately and without seeking professional assistance. This step generally includes things like missing patient details, incorrect spellings, missing diagnosis codes etc. If a claim is rejected for this step, it can be corrected and resubmitted.
  • The Automatic Review: During this step, a claim is usually checked for more specific details that pertain to the insurance payers payment terms and policies. It is usually known as the eligibility check and is an automated procedure.
  • The Manual Review : This process includes medical claim examiners going through the claim forms manually to determine any mismatch. Medical records could be requested during this step to review the claims aptly.
  • The Payment Determination: During this step, a claim could possibly have 3 outcomes. A claim could go as either paid, denied or reduced.
  • The Payment: The last and final step is when the insurance company makes the payment to the medical office along with an explanation of the payment, the reason for the reduction if any reduction was made, reason for rejection etc. This is usually called a remittance advice or explanation of payment.

Max Services Inc. provides you with medical claim experts who are well aware of the healthcare laws and HIPAA regulations. Our experts ensure that your claims are analyzed with utmost care and attention to avoid denials. With Max Services Inc. you can rest assured that your claims billing is error free and efficient, at all times!