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    03 — Value stream · VS-530

    Claim-to-Payment

    Receive a provider's or member's claim, check it against eligibility, benefits, authorizations and the provider's contract, decide and price it, pay it, and find and recover any payment that should not have been made. A provider's billing of the claim is Encounter-to-Cash.

    • Claims Lifecycle
    • Claim Processing
    • Adjudicate-to-Pay
    • Payer Claims Flow
    // FIG. 03 · Stage flow
    1Receive & Validate2Check Authorizati…3Adjudicate & Price4Screen Payment5Pay & Explain6Resolve Appeals &…7Recover & Settle
    1. 01

      Receive & Validate

      VS-530.10

      Receive the claim, validate its data and match it to the member and the provider.

    2. 02

      Check Authorization

      VS-530.20

      Check the claim against prior authorizations and medical necessity decisions.

    3. 03

      Adjudicate & Price

      VS-530.30

      Apply benefits, coverage policies and contract terms to decide and price each service.

    4. 04

      Screen Payment

      VS-530.40

      Screen the claim before payment for errors, duplicates, coordination of benefits and possible fraud.

    5. 05

      Pay & Explain

      VS-530.50

      Pay the provider or member and send the remittance and the member's explanation of benefits.

    6. 06

      Resolve Appeals & Disputes

      VS-530.70

      Hear member appeals and provider disputes of the decision, and reprocess the claims that are overturned.

    7. 07

      Recover & Settle

      VS-530.60

      Recover overpayments, pursue other liable parties and settle value-based contract amounts.