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Insights on healthcare security and third-party risk, AI in claims processing, and regulatory compliance for payer organizations.
Claims adjudication refers to the stage in a claims lifecycle where the payer or insurer conducts an in-depth evaluation of a claim submitted by a provider. The evaluation process requires the payer to affirm the relevancy of a claim and ensure that it does not contain any errors regarding a patient’s personal information and that there are no omissions. The payer also needs to check for coding appropriateness and accuracy under medical codes, such as the Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS).
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