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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This note was uploaded on 06/21/2011 for the course HCR 230 taught by Professor Volk during the Spring '11 term at University of Phoenix.
- Spring '11