What process occurs after a third-party payer validates a claim?

After a third-party payer validates a claim, the next step in the process is claim adjudication. During this phase, the payer reviews the claim in detail to determine whether it meets their guidelines for payment, which includes assessing the accuracy of the information, appropriateness of the services rendered, and verification of patient eligibility and coverage for the services.

Claim adjudication involves various outcomes such as approval, partial payment, or denial based on the terms of the insurance policy. This process is crucial as it determines the financial responsibility of both the payer and the patient. Effective adjudication ensures that claims are processed efficiently and accurately, facilitating proper reimbursement for the healthcare provider while ensuring that the payer adheres to their policies and contractual obligations.

In contrast, claim submission is the initial step where claims are sent to the payer, claim rejection is when a claim fails to meet the criteria set by the payer resulting in it not being processed, and claim approval occurs when the claim is found acceptable for payment, which is a result of the adjudication process rather than a step that follows it.