Which statement best defines claim adjudication?

Which statement best defines claim adjudication?

• A. It is the process of appealing a denial
• B. It is the payer's determination of the payment amount after reviewing the claim
• C. It is the initial submission of a claim
• D. It is the collection of payments from a patient

Answer: (B)

Adjudication is the payer’s determination of the payment amount after reviewing the claim. After a claim is submitted, the payer’s system checks that the patient is eligible, the service is covered under the benefit plan, and the codes (CPT/HCPCS and ICD) are appropriate and medically necessary. The payer then applies the plan’s rules—benefits, deductible, coinsurance, copays, and any contract adjustments—to calculate the allowed amount. What remains the patient’s responsibility is determined (if any) and the payer decides whether to pay in full, pay a portion, or deny the claim with a reason. The result of this process is the Explanation of Benefits and any payment issued. This is distinct from simply submitting a claim, appealing a denial, or collecting payment from the patient.

Adjudication is the payer’s determination of the payment amount after reviewing the claim. After a claim is submitted, the payer’s system checks that the patient is eligible, the service is covered under the benefit plan, and the codes (CPT/HCPCS and ICD) are appropriate and medically necessary. The payer then applies the plan’s rules—benefits, deductible, coinsurance, copays, and any contract adjustments—to calculate the allowed amount. What remains the patient’s responsibility is determined (if any) and the payer decides whether to pay in full, pay a portion, or deny the claim with a reason. The result of this process is the Explanation of Benefits and any payment issued. This is distinct from simply submitting a claim, appealing a denial, or collecting payment from the patient.