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What is claim adjudication process in healthcare


After a medical claim is submitted, the insurance company determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. The insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.

What is a claim adjudication?

Claims adjudication is the process by which insurance companies review healthcare claims and decide whether they will pay the claim in full, pay a partial amount, or deny the claim altogether. If more information is needed, the claim will be rejected and marked as pending.

What are the steps in processing a claim?

Step 1: Reporting the claim\n\n The first step in filing a claim involves reporting the accident to the insurance company.




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