What does adjudicated a medical claim mean?

When a medical claim is "adjudicated," it means that it has been processed by the insurance company or claims administrator. This process involves checking the claim for eligibility, reviewing it for medical necessity, and determining the appropriate amount to pay for the services provided.

As part of the adjudication process, the insurance company will check to make sure that the patient is a covered person under the insurance policy. They will also verify the provider's license and certification. The insurance company will then determine if the services provided are medically necessary. This means that the services must be considered necessary to treat the patient's condition and that there are no other reasonable alternative treatments.

Once the medical claim has been reviewed, the insurance company will determine the appropriate amount to pay for the services. This is based on a number of factors, including the type of services provided, the usual and customary charges for those services, and the coinsurance or copay requirements of the insurance policy.

The insurance company will send a notice to the patient and provider explaining the results of the adjudication process. If the claim is approved, the insurance company will make payment directly to the provider. If the claim is denied, the patient may appeal the decision with the insurance company.

If a medical claim is denied, the patient may also be responsible for paying for the services provided and may be able to file a complaint with the state insurance department.