Claims Adjudication

Claims adjudication is the process by which insurance companies review and determine whether a healthcare service or treatment qualifies for coverage. When a healthcare provider submits a claim, the insurer evaluates the details, such as the patient's coverage, medical necessity, and policy rules. Based on this review, the insurer decides to approve the claim, pay a certain amount, deny it altogether, or request more information. This process ensures that claims are handled fairly and accurately, helping both patients and providers understand what costs are covered and what they may need to pay out-of-pocket.