HCR 230 Week 9 Capstone - services medical review...

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Automated Review Payment Determination Manual Review Initial Process Capstone CheckPoint There are five steps that are in the claims adjudication process and these steps consist of the initial process, automated review, manual review, determination and payment. In the initial process, there could be many problems that arise such as the patient’s name, plan of service code or the plan identification number being incorrect. The diagnosis code may also be incorrect with errors consisting of the date of service being wrong or missing altogether. There might also be an error reporting a gender- specific code and the patient’s gender not matching up. Any claims that have mistakes are automatically rejected. The provider is then instructed by the payer to correct those errors and resubmit the claim. The claim goes through the automated review after the initial process. This review looks at the patient’s time limits for filing claims, referral forms, preauthorization and the patient’s eligibility benefits. Bundled codes, non-covered
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Unformatted text preview: services, medical review, concurrent care, utilization review and duplicate dates of service are also checked during the automated review to ensure there are no errors. The claim is stopped if problems are found. The claim is then set aside for manual review. During this review, more information might be requested in order for the claim process to be completed. An examiner receives the claim, and this person can ask the provider for any additional information necessary for processing the claim. Once every mistake has been fixed, the claim is sent for the determination process. At this time, the decision is made for payment, denial, or payment at a reduced rate. Once this has happened, the payment (if applicable) is sent to the service provider, along with an explanation of the decisions of payment. This adjudication process is important because it catches any errors that may have been processed on the claim....
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