NETMARK CLAIMS ADJUDICATION WORKFLOW
Initial Claims Processing Review
Thorough error, omission and correction check, including:
- Wrong patient name
- Wrong date of service
- Wrong place of service code
- Wrong subscriber identification number
- Invalid diagnosis code
- Missing diagnosis code
- Incorrect CPT code given diagnosis code
- Patient gender service mismatch
Detailed Claims Processing Review
Payment policy identification issues, including:
- Date of service patient eligibility
- Duplicate claims identified
- Missing authorization
- Absence of pre-certification
- Invalid authorization
- Invalid pre-certification
- Invalid procedure code
- Invalid diagnosis code
- Filing deadline passed
- Services are not medically necessary
Medical Review
Claim examiners, nurses and doctors checks, including:
- Manual claims checking
- Medical documentation and claims comparison
- Medical procedure assessment
- Not listed procedure examination
Payment Determination
There are four types of payment determinations, including:
- Paid: A determination that the claim is reimbursable
- Pended: More information is required to make a payment determination
- Reduced: The claims examiner down-codes to a lower level given the diagnosis
- Denied: A determination that the claim is not reimbursable
Payment
Explanation of payment to the medical provider, including:
- Allowed amount
- Approved amount
- Paid amount
- Covered amount
- Adjudication date
- Discount amount
- Patient Responsibility amount
- Claims amount