What process evaluates claims for payment by an insurance carrier?

The process that evaluates claims for payment by an insurance carrier is known as adjudication. This is a critical step in the revenue cycle where the insurance company reviews the claim submitted by the healthcare provider or patient to determine whether it is valid, whether the services are covered under the patient's plan, and how much the insurance will pay versus what the patient is responsible for paying.

During adjudication, the insurance company will assess various factors, including the appropriateness of the billed services, the patient's eligibility at the time of service, and any policy limitations that may apply. The objective is to arrive at a final decision on the claim, which will then inform the provider and the patient of their respective financial responsibilities. Adjudication is a key component of ensuring that the payment process is efficient and accurately reflects the terms of the insurance coverage.

Utilization review, while related to the overall process of managing claims, is specifically focused on determining whether the services provided were medically necessary. Pre-authorization refers to the requirement that certain services must be approved by the insurance company before they are provided. Claim validation involves checking for the completeness and accuracy of the claim but does not encompass the broader evaluation of payment as adjudication does.