Healthcare Claims Adjudication Services

Initial Claims Processing Review

We believe the first step in the claims review process is also the most important since all claims with simple errors and omissions can be returned at this stage itself, thereby reducing processing load down the line. During this phase, we check for the following -

Incorrect patient names and other spelling mistakes

Incorrect identification numbers / plan numbers/ member IDs

Invalid or missing diagnosis code

Incorrect service dates

Incorrect service codes

Patient's gender mismatch

Automatic Claims Review

During this phase, an in-depth check of the claims is made to get specific details pertaining to the payer's payment policies. This step is important since many incorrect payouts can be stopped at this stage itself. Issues identified during this phase include -

Submission of duplicate claims

Claims which have already been submitted for the same date/procedure/by the same person are flagged

Unnecessary Service Delivered

Occasionally claims are made for inappropriate and expensive services which could have been easily avoided for cheaper alternatives or quicker procedures

Invalid Diagnosis and Procedure Codes

Diagnostic and procedure codes are sometimes listed wrongly in the claims, and when caught, can save you further trouble

Invalid Pre-authorization

Occasionally, the diagnosis, surgery, or performed procedure fails to match with the information provided during pre-authorization

Deadline Timing Has Passed

If the medical claim is submitted after the deadline has passed as ascertained by your insurance policy, then the claim processing is stopped

Patient Eligibility

If the patient is ineligible to apply for the claim either due to claim mismatch, missed payments, etc., then the claim can be rejected in such a scenario

Final Manual Claims Review

During this stage, our experienced team of medical and healthcare claims examiners starts checking the claims for the further mismatch. For the same, they may ask for copies of medical records and other relevant documentation to check the authenticity of the claim. This step is extremely crucial when claims are made for unlisted procedures and when the medical necessity for the same needs to be validated.

Payment Determination

There are mainly three types of payment determinations we use at Flatworld Solutions, they include -

Paid

The insurance payer determines the claim can be reimbursed when the healthcare claim is considered paid

Denied

The payer determines that the claim cannot be reimbursed when the healthcare claim is considered as denied

Reduced

The procedure code can be down-coded when the billed service level is considered too high based on the diagnosis

Payment

In the final stage, we submit the payment to the office supplied by the payer and is called the explanation of the payment. This includes information such as explanation reasons for the reduction in payment, denial, adjustment, etc. It also includes information such as allowed amount, paid amount, approved amount, covered amount, patient responsibility amount, adjudication date, etc.

Our exhaustive 5-step verification process ensures all your data is verified so that improper claims are processed properly. We cover a variety of healthcare claim types for our US-based and global clients, including -

HCFA claims 1500 / CMS1500

UB04

UB92 (Single / Multi / Attachment / COB)

Dental Claims

RX claims

Medicaid

Foreign claims

Superbill

Medicare RP

Miscellaneous (complex / non-standard)

Pends / Correspondence

Enrollment Forms Processing (EFP)

Vision Claims