Which stage involves the payer deciding if a claim is payable and for what amount?

Which stage involves the payer deciding if a claim is payable and for what amount?

• A. Adjudication
• B. Submission
• C. Merger
• D. Denial

Answer: (A)

Adjudication is the stage where the payer reviews the submitted claim and decides whether it should be paid and for what amount. After a claim is submitted, the payer checks eligibility and benefits, applies patient cost-sharing, verifies coding and medical necessity, and determines the allowed amount. The outcome can be a payment to the provider, a reduced payment, or a denial if coverage doesn’t apply. Submitting simply sends the claim to the payer, and Merger isn’t relevant to how claims are processed.

Adjudication is the stage where the payer reviews the submitted claim and decides whether it should be paid and for what amount. After a claim is submitted, the payer checks eligibility and benefits, applies patient cost-sharing, verifies coding and medical necessity, and determines the allowed amount. The outcome can be a payment to the provider, a reduced payment, or a denial if coverage doesn’t apply. Submitting simply sends the claim to the payer, and Merger isn’t relevant to how claims are processed.