What is the purpose of claim adjudication?

The purpose of claim adjudication is to review claims for accuracy based on various criteria. This process involves assessing the details of the claim submitted by a healthcare provider to ensure that it meets the requirements set by the insurance company or payor. During adjudication, claims are examined for their validity and compliance with policies, including the medical necessity of services rendered, appropriate coding, coverage policies, and the patient's eligibility for benefits.

The outcome of this process determines whether the claim is approved for payment, denied, or adjusted. This step is essential in ensuring that reimbursements are made for medically necessary services and that fraudulent or incorrect claims are identified and addressed. Claim adjudication also plays a key role in maintaining a sustainable healthcare system by controlling costs and ensuring that claims are processed efficiently and accurately.