Medical Billing: Monitoring the Claim

The moment a claim gets to the payer, it usually undergoes adjudication, wherein the insurance company assesses a reimbursement claim, and from there, decides whether the claim is valid and how much is the coverage of the insurer. In this stage the claim may be accepted, denied, or rejected by the insurer. In practice, an accepted claim means that such has been found valid by the insurer. But, the payer will not automatically assume the payment of the entire cost.

In fact, what the payer will do is to process the reimbursement claim within the standards of the arrangement. On the other hand, a rejected claim is such that the payer has discovered an error on the face of the claim. When a claim is lacking essential patient information, the claim will be rejected. The same will be returned to the medical billing company for correction, without prejudice to its resubmission.