CLAIM ADJUDICATION SERVICES

claim adjudication services

Types of Claims We Process and Adjudicate :

  • HCFA1500 / CMS1500
  • UB92/UB04
  • NO FAULT & WORKERS COMPENSATION

Claims Adjudication Team :

Our adjudicators have clinical knowledge and exceptional analytical skills. They have been trained in the U.S. healthcare processes and claims adjudication systems and processes. Each adjudicator goes through rigorous training on our customers' processes and subsequently develops proficiencies in a simulated environment.

Pre-certification & Insurance Verification :

The patient list, a copy of the insurance card and demographic details are sent to us via email/fax or secure FTP. Our medical billing specialists call up the insurance company prior to the appointment. Pre-certification is done for specific lab tests, diagnostic tests and surgeries. The details are sent to the hospital/clinic in the prescribed format.

Patient Demographic Entry :

The medical billing specialists enter patient demographic details such as name, date of birth, address, insurance details, medical history, guarantor etc as provided by the patients at the time of the visit. For established patients, we validate these details and necessary changes, if any, are done to the patient records on the practice management system.

CPT and ICD-9 Coding :

Our coding team consists of AAPC certified coders with over 2 years of multi-specialty coding experience. You may send us superbills with diagnostic notes with or without ICD and CPT codes. If codes are already provided on the superbill, they are validated by our coding team compulsorily to prevent any 'up-coding' or 'down-coding' and therefore, any denials.

Charge Entry :

The fee schedules are pre- loaded into the practice management system. CPT and ICD-9 codes are entered into the system. The billing specialists ensure that all details have been provided in the claim and ready to be filed.

Claims Submission :

Claims are submitted electronically via the practice management system. However, we can process paper claims also. At this stage, a thorough quality check is done by a senior billing specialist and then submitted. The rejection report received from the clearing house, if any, is analyzed and the necessary changes are done. These claims are then resubmitted.

Payment Posting :

Scanned EOBs and checks are sent to our team. All payments are entered into the system. The amounts from EOBs/checks and amounts posted in the system are reconciled on a daily basis. A daily log is updated with these data along with any rejections on it.

Account Receivables Follow-up :

All claims in the system are examined and priorities are set. First the Current EOB denials then the claims close to their filing limit and then it’s worked down from the age of the claim. Periodic follow-ups over phone, email and/or online is done to get the status of each claim submitted to the insurance company.

Denial Management :

Analysis of denials and partial payments is done by our senior medical billing specialists. Payers, patients, providers, facilities and any other participants are called to follow-up on denied, underpaid, pending and any other improperly processed claims and the action is documented in the system. We will call patients, if authorized by the provider, to obtain information from the patient needed for billing such as ID# and to update the COB (Coordination of benefits) with their insurance companies. Secondary paper claims are processed and sent to the client office for submission.

claim adjudication services