Adjudication is defined as a legal process involved in settling disputes between two warring parties without resorting to extensive and costly court procedures. The term adjudication is used in the insurance industry to refer to the channel or process of paying or declining payment of claims after comparing the presented claims to the insurance coverage or benefits requirements (Vines-Allen et al 23). Therefore, any time an individual files a claim with an insurance company, what follows is the justification and payment process acknowledged as the insurance adjudication. According Vines-Allen et al (19), this process normally entails obtaining a claim from an insured individual or claimant, and then manually or electronically processing the said claim, and in turn making a decision on the provided facts on whether to pay or not pay. During the adjudication procedure, the insurance company is normally served with the responsibility of weighing the magnitude of the claim provided against the insurance coverage or health cover possessed by the claimant (Vines-Allen et al 76).
The main steps involved starts with establishing whether the claimant is qualified or eligible for sought after benefits, then its followed by determination of whether the provided insurance coverage covers for the provided treatment (Vines-Allen 77). Then, this is followed by the adjudication process that confirms the status of the claimant, and finally the determination of the payment obligation of insurance company and the insured. With many insurance companies, this process is automated and mostly it’s very fast with final decision available within hours or even few days. If the patient or claimant is determined to be an eligible insured, but there is no reimbursement paid to the rendering provider, a contemporaneously created explanation of benefits (EOB) is still sent out to the insurance plan holder together with the providing healthcare provider detailing reasons why such claim won’t be honored (Vines-Allen 121).
Work Cited
Vines-Allen Deborah, Rollins Elizabeth Braceland Ann & Miller Susan Peterson. Comprehensive Health Insurance: Billing, Coding and Reimbursement. Second Edition. New York: Pearson.Print.
