Scene 1 (0s)
Claims Adjudication Process. Healthcare / Insurance Workflow Avasarala Pavan Kumar.
Scene 2 (7s)
Introduction. Claims adjudication is the process used by insurance companies to review and process claims submitted by healthcare providers..
Scene 3 (17s)
Objectives. • Verify coverage • Ensure medical necessity • Detect errors • Apply policies • Calculate payment.
Scene 4 (24s)
US Healthcare Example. Example: Patient visits doctor → Provider submits claim (837) → Payer processes → Payment (835).
Scene 5 (33s)
Claims Adjudication Flowchart. Claim Submission. Initial Review.
Scene 6 (43s)
Denial Management Lifecycle. Denial Received. Analysis.
Scene 7 (52s)
Technology in Adjudication. • Automation • AI • EDI • Analytics • Claims Software.
Scene 8 (59s)
Conclusion. Claims adjudication ensures accurate payments and financial stability..