Adjudication

What does “adjudication” mean?

Adjudication is the process that the insurer uses to pay you for their client’s visit. During this process, they review the claim to either pay or deny it.

What is the process?

In this process, the insurer details the explanation, or reasons, for accepting, denying, or reducing the payment or deciding which charges will be uncovered. The remittance will describe, or explain, their reason for dealing with the claim as such. In the most basic terms, this is a process of dispute resolution, allowing all parties that are involved to present their case for resolution of the claim.

What is the adjudication date?

This is simply the date on which the decision to pay, deny or send back for resubmission of a claim takes place.

What does it mean that the claim was “adjudicated”?

This refers to the process of resolving a dispute or coming to a resolution for a claim. This means that the facts have been reviewed, and the result has been decided based on all of the evidence or examination provided.

What is an adjudicator?

In medicine this is someone that uses their own knowledge of health and health science, as well as the information provided by all parties to the claim to determine the resolution of the claim, whether it is approved, denied, or due for resubmission.

If you’d like to take a break from all of the high-level back-and-forths with insurers, our Gables Medical Billing team is more than happy to guide your claims through adjudication, handling all claims submissions, follow-ups, appeals, and payment posting with the dedication your practice deserves.