After a third-party payer validates a claim, what occurs next?

After a third-party payer validates a claim, what occurs next?

• A. Claim adjudication
• B. Patient notification
• C. Rejection of the claim
• D. Preauthorization

Answer: (A)

The next step is adjudication. Once a claim has been validated, the payer reviews it against the patient’s benefits, eligibility, and the contract terms to determine how much of the billed amount is covered, how much the patient owes, and whether the service is payable. This process results in a payment decision (or denial) and is documented in a remittance advice or explanation of benefits. Preauthorization happens before services are rendered, to determine if coverage will apply; patient notification typically follows after adjudication, when the payment decision is communicated.

The next step is adjudication. Once a claim has been validated, the payer reviews it against the patient’s benefits, eligibility, and the contract terms to determine how much of the billed amount is covered, how much the patient owes, and whether the service is payable. This process results in a payment decision (or denial) and is documented in a remittance advice or explanation of benefits. Preauthorization happens before services are rendered, to determine if coverage will apply; patient notification typically follows after adjudication, when the payment decision is communicated.