Week 9 CAPSTONE CHECKPOINT

Week 9 CAPSTONE CHECKPOINT - The Claims Adjudication...

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The Claims Adjudication Process The adjudication process is important to the medical billing process because the adjudication process was designed to determine how claims should be paid. The purpose for the Initial Processing is to find problems such as if patient’s name, plan identification number, or place of service code is wrong. The date for provided services might be incorrect or a diagnosis code could be missing or patient may be entered as the wrong sex for a reported gender-specific procedure code. Claims which include these simple mistakes and minor errors are rejected, and the payer instructs the provider to correct all errors. Once this happens the medical claim should be corrected with the sufficient information and a clean claim should be submitted, which is acceptable by the payer for immediate processing of the claim (Valerius et al., 2008) After the payer has accepted the claim the Payers’ computer systems will apply edits that replicate their payment policies. For example, a Medicare claim is subject to the Correct Coding
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Week 9 CAPSTONE CHECKPOINT - The Claims Adjudication...

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