HCR 230 week 9 checkpoint

HCR 230 week 9 checkpoint - limit for filing claims...

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Claim Adjudication Process The claim adjudication process is a five step process designed to determine how a claim should be paid. This process is important because it ensures that the provider is paid for correct procedures rendered. The first step of the process is known as the initial process. During the initial process problems such as patient’s name, plan identification number, or place of service code could be wrong on the claim. The diagnosis code can either be missing from the claim or not match the date of service rendered or the sex of the patient may not match that of the document from the procedure rendered. This is an important part of the process because if there are any errors or mistakes the claim will be rejected. The physician is instructed by the payer to correct mistakes and resubmit the claim within a specified time frame. The second step in the process is the automated review. During this step the review looks at the patient’s time
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Unformatted text preview: limit for filing claims, referral forms, preauthorization, and the patient’s benefits eligibility. Also checked during the automated review process are bundled codes, non covered services, medical reviews, concurrent care, utilization review, and duplicate dates of service. If any problems are found during the automated review it is then set aside and goes through the third step which is manual review. During the manual review process information is collected so that the claim can be finished. For example if there are errors found the personnel working on the manual review can as the physician for any additional information to process the claim. Once all errors are collected the process goes into the fourth step which is determination. During the determination step the decision for payment is made, denied or reduced. Finally the claim is paid (if accepted), sent to provider with an explanation of decision....
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