What is the process called that health plans follow to review claims for payment?

The process referred to in this context is known as claims adjudication. This is a critical step in the healthcare reimbursement process where health plans evaluate the claims submitted by providers for payment. During adjudication, the health plan reviews claims to determine if the services rendered are covered under a patient's insurance policy, whether the charges are appropriate, and if the necessary documentation has been provided.

Claims adjudication involves several key steps, including verifying patient eligibility, assessing the medical necessity of the services, applying relevant benefit policies, and checking for any coding discrepancies. This comprehensive review ensures that only authorized claims are paid, thereby protecting both the insurer and the provider from potential fraud or billing errors.

This process is essential for maintaining the integrity of the healthcare payment system and ensuring that providers are compensated fairly for their services while adhering to the contractual obligations of the insurance policies.