Claims Operations & Adjudication

A claim arrives and the system asks, in order, the questions a person would: is this member enrolled on the date of service, is this provider on file with a contract in force that day, does the benefit cover this service and at what member share once the deductible and out-of-pocket accumulators are applied, was an authorization required and is there one on file that matches what was billed, what do the contract terms say this is worth, and do the codes hold together. If every answer lands, the claim finishes without anyone seeing it and the remittance goes back electronically. The share of claims that finish that way is your number, and it is the number everyone asks you about. You watch it by line of business, by group, by provider and by claim type, and you spend the week on why it moved: a new group loaded with a benefit the configuration cannot quite express, a fee schedule that did not get loaded before its effective date, a provider record carrying two overlapping contracts, a code set that turned over at the start of the year, duplicate logic tight enough to stop a legitimate repeat service or loose enough to let the same claim pay twice. Paper claims and claims with attachments come in on their own path, and they carry work that has to happen before the adjudication questions can even be asked.

These are the claims that stopped. Each carries a code saying why: member not found on the date of service, provider not on file or not effective that day, no benefit configured for this service, an authorization required and none on file, an authorization on file that does not match what was billed, other coverage on record with nothing to say how it applies, possible duplicate, no price because no contract is loaded, records needed, an amount over the review threshold. The code is where the similarity ends. Some you resolve at your desk in a minute. Some are not yours at all, because the fix lives in enrollment, in the provider file, in benefit configuration, in clinical review, or with the provider who has to send something. You work an aged queue in which the oldest claims are the ones nobody could resolve, the clock on the plan's payment obligation runs the whole time you are working them, and the claim you touched last week can come back on the same code, because the first touch fixed the claim rather than the thing that stopped it.

You are the check between adjudication and the payment file. A claim that passed the edits is payable, which is not the same as correct, so you look at the ones worth looking at. The code pair that should not have been billed together and the modifier appended to make it pass. The visit billed alongside a procedure it is normally part of. The assistant surgeon on a procedure that does not usually have one. The inpatient stay whose coded principal diagnosis and complication drive a payment the record may not support. The high-dollar claim where you want the itemized bill and the implant invoice before anything moves. The drug claim where the billed units and the package do not agree. The member who has other coverage that should have paid first, or a claim whose diagnosis and circumstances say somebody else's liability is in play. You work against a payment deadline, because a claim you hold can become a claim you owe interest on, and against a provider who will see the same reduction across many claims and call about all of them at once.

A provider disagrees with what you paid, and says so in whatever form their billing office uses: a dispute form through the portal, a letter with records attached, a call from a revenue cycle team working its own worklist, or a corrected claim resubmitted as a replacement rather than as a new claim, which is a dispute even though it does not arrive labeled as one. You work out what is actually being contested. That the claim was denied for something that was in fact on file. That a code was reduced or the claim repriced. That the contract term applied is not the one they signed. That a timely filing denial should be waived because the claim went somewhere else first. That the reduction from a pre-payment review was wrong. What the process is called, and the clock attached to it, depend on the line of business and the contract, a contracted provider's dispute, a non-contracted provider's appeal, an out-of-network claim of the kind the federal independent dispute resolution process, and getting the track wrong means missing a deadline that was never yours to extend. Members can be affected by what you decide here without appearing anywhere in the file.