U.S. Healthcare Claims Adjudication Process Flow Chart
Healthcare services in the United States are expensive, and it is not uncommon for patients to file insurance claims for medical treatments. The healthcare claims adjudication process flow chart is a critical tool for understanding how insurers handle these claims.
What is Healthcare Claims Adjudication?
Healthcare claims adjudication is the process of determining the validity of a healthcare claim and deciding whether to pay it or deny it. This process involves several steps and requires coordination between healthcare providers, patients, and insurance companies.
The Healthcare Claims Adjudication Process Flow Chart
The healthcare claims adjudication process flow chart is a visual representation of the various steps involved in processing a healthcare claim. It starts with the patient receiving medical treatment and ends with the insurance company paying or denying the claim.
Step 1: Patient Receives Medical Treatment
The healthcare claims adjudication process flow chart starts with the patient receiving medical treatment. This could include anything from a routine check-up to emergency surgery.
Step 2: Provider Submits a Claim to the Insurance Company
After the patient receives medical treatment, the healthcare provider submits a claim to the patient's insurance company. The claim includes information about the treatment provided, the cost of the treatment, and other relevant details.
Step 3: Insurance Company Receives the Claim
The insurance company receives the claim from the healthcare provider and begins the adjudication process. This process involves reviewing the claim and determining its validity.
Step 4: Claim is Processed
Once the insurance company receives the claim, it is processed using a variety of tools and resources. This could include computer programs that analyze the claim and compare it to other similar claims to determine its validity.
Step 5: Claim is Approved or Denied
After the claim is processed, the insurance company will either approve or deny the claim. If the claim is approved, the insurance company will pay the healthcare provider for the cost of the treatment.
Step 6: Explanation of Benefits (EOB) is Issued
Once the claim is approved or denied, the insurance company will issue an Explanation of Benefits (EOB) to the patient. This document explains how the claim was processed, how much the insurance company paid, and how much the patient is responsible for paying.
Step 7: Patient Pays Remaining Balance
After receiving the EOB, the patient is responsible for paying any remaining balance. This could include deductibles, co-pays, or other out-of-pocket expenses.
Conclusion
The healthcare claims adjudication process flow chart is a critical tool for understanding how insurers handle healthcare claims. By following this process, patients can ensure that their medical treatments are covered by their insurance companies and that they are responsible for paying only their share of the cost.