02 — Capability · BC-1870.40
Claims Adjudication
Decide every medical claim correctly and on time against the member's eligibility, benefits and the provider's contract, pay it, explain the decision, and hear appeals and disputes. Pharmacy claims are pharmacy benefit administration (BC-1870.20.50); submitting and following up claims as a provider is revenue cycle.
- Claims Processing
- Payer Claims Operations
- Medical Claims Adjudication
In scope
- Claim intake, validation and pending
- Contract pricing and automated adjudication
- Provider payment, remittance and explanations of benefits
- Member appeals and grievances, and provider payment disputes
Out of scope
- Submitting and following up claims as a provider (see BC-1840.30)
- A provider appealing its own denials (see BC-1840.40)
- Prepayment and postpayment review for fraud, waste and abuse (see BC-1870.60)
Realized by · 6
- ServiceNow · Healthcare and Life Sciences Service Managementpartial via BC-1870.40.40
- Salesforce · Health Cloudpartial via BC-1870.40.60
- HealthEdge · HealthRules Edge Claims Administrationcore via BC-1870.40.10
- HealthEdge · Home and Host Processingpartial via BC-1870.40.10
- HealthEdge · Payment Accuracy Edgestrong via BC-1870.40.20
- HealthEdge · Clinical Edge Appeals and Grievancesstrong via BC-1870.40.60
Used in · 4
Build it · 1
Decomposes into · 6
- BC-1870.40.10Medical Claim IntakeReceive claims electronically and on paper, check them for completeness and valid codes, and reject or pend those that cannot be processed.
- BC-1870.40.20Contract Claim PricingPrice each claim against the provider's agreement, fee schedule or out-of-network rules before benefits are applied.
- BC-1870.40.30Automated AdjudicationApply eligibility, benefits, cost sharing and edits to decide each claim without manual handling wherever the rules allow, and raise the share decided that way.
- BC-1870.40.40Pended Claim ResolutionWork claims that stop for review, gather missing information, and decide them within prompt-pay time limits.
- BC-1870.40.50Provider Payment & RemittancePay providers by claim, capitation or other contract arrangement, send remittance advice, and send members explanations of benefits as required.
- BC-1870.40.60Appeals, Grievances & DisputesHear member grievances about service and quality of care, member appeals of authorization, coverage and payment decisions, and provider payment disputes, decide each within regulatory time limits, and route them to external review when requested.