HCR 230 Capstone
When the payer gets a claim, it is sent out electronically to the sender showing that the process has been complete. Each claim then goes through what is called adjudication which is made up of five steps intended to evaluate how each claim should be paid. The first step is the initial processing in which each claim’s information is reviewed by the payer’s front-end claims processing system. If any errors are found, claims are denied, and the payer sends orders to the provider to fix any errors and/or information excluded and to resubmit for rebilling of the service. The second step is the automated review in which the payers’ computer systems make any changes that indicate a medical provider’s payment policies. The third step is the manual review in which if any problems have resulted from the automated review, that claim is put on hold and put off by payers because more information is needed for claim processing. The fourth step is the determination in which a decision is made on if they should pay the claim, deny the claim, or pay the claim at a reduced level. Lastly, the fifth step is payment in which if money is owed, the payer sends any necessary information to the provider along with a remittance advice (RA) or electronic remittance advice (ERA), a process that explains the payment decisions to the provider. Without the relationship between each step the process will become out of whack and medical providers may not get paid for their services and it will fall upon the patient. Medical billing is the core competency to and service provider that way they can efficiently manage all your billing needs.
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