Talk To An Expert



Headquarters: 300 E-Business Way, Suite 200 Cincinnati. OH 45241

[email protected]

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


 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