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Claims Adjudication Services

Claims Adjudication Services

Claims adjudication is an important task for insurance providers as it prevents instances of duplicated claims, unwanted claims, delayed execution, etc. Even the right claims when mismanaged can have adverse effects on the company. Inefficient healthcare claims adjudication will eventually adversely affect the firm's revenue.

Outsource2india has been offering offshore claims adjudication services to large insurance carriers and TPAs (third-party administrators) for over 20 years now. Our claims adjudication approach is simple - engaging a team of experienced and qualified claims adjudicators and a team of IT professionals to deliver efficient adjudication solutions to payers. We provide you with a blend of skilled resources, efficient processes, quality systems, and advanced technology, to assure exceptional quality, efficiency and cost savings.

Claims Adjudication Services We Offer

Outsource2india has been providing global clients with high-quality healthcare claims adjudication services for almost two decades now. Being in the industry for so long, we have the required knowledge and experience to efficiently carry out claims adjudication and can cater to any type of client requests.

Our team of adjudicators can help you manage claims in the most efficient manner. Some of the major types of claims we can help you process include-

 Medical Claims Processing
 PPO Repricing
 Forms Processing
 Insurance Fraud Detection
 HCFA 1500 / CMS 1500
 Dental Claims
 Pends / Correspondence
 Enrollment Forms Processing (EFP)
 Miscellaneous (Complex / Non-standard)
 EDI Integration

Claims Adjudication Process We Follow

With extensive experience in the healthcare insurance industry, we understand each and every type of complication that may arise in this process. Our team is experienced in handling such complications and understanding process intricacies to provide efficient services within a quick turnaround time. This is possible by following a systematic and streamlined claims adjudication process. The steps involved in our process are listed here -

Initial Processing Review  

01. Initial Processing Review

In the first step, the claims are thoroughly checked for errors and omissions. The claim can be corrected and resubmitted for payment when the claim is rejected for any of the following reasons -

  • Incorrect or wrong patient name
  • Wrong plan or subscriber identification number
  • Incorrect place of service code
  • Wrong date of service
  • Invalid or missing diagnosis code
  • Mismatch of service and patient's gender
Automatic Review  

02. Automatic Review

In this step, claims are checked in detail for items which apply to the payment policies. The issues identified during the automatic review include -

  • Eligibility of the patient on the date of service
  • Absence of authorization and pre-certification
  • Invalid authorization and pre-certification
  • Duplicate claims are submitted
  • Filing deadline has been crossed
  • Invalid procedure or diagnosis code
  • The services are not necessary medically
Manual Review  

03. Manual Review

In this step, medical claim examiners check the claims manually. It is common for nurses and doctors to perform manual checks and compare the medical documentation with the claims. This step is performed for any type of medical procedure and is especially done for a procedure which is not listed.

Payment Determination  

04. Payment Determination

There are basically three types of payment determinations. They are -

  • Paid - If the claim is considered paid, the payer determines if the claim is reimbursable
  • Denied - If the claim is considered denied, the payer determines that the claim is non-reimbursable
  • Reduced - When the billed amount is too high for the diagnosis, the claims examiner can down-code to a lower level as deemed appropriate

05. Payment

The payment submitted by the insurance payer to the medical care provider is referred to an explanation of payment. It includes the following data -

  • Allowed Amount
  • Covered Amount
  • Patient Responsibility Amount
  • Approved Amount
  • Payer Paid Amount
  • Discount Amount
  • Adjudication Date
24 hours
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Why Choose Us for Claims Adjudication?

Being a leading provider of healthcare BPO services to clients worldwide, we have the required skills and expertise to handle any type of client requests. Outsourcing claims adjudication services to us can help you take advantage of the following benefits -

  • Affordable Services

    All our clients will be billed based on the number of claims processed per day, work volume, etc. This assures quick and efficient services at affordable rates

  • Data Security

    We are an ISO/IEC 27001:2013 ISMS certified organization. We sign confidentiality agreements and have data security policies in place to ensure that all your critical data remains completely safe with us

  • HIPAA Compliance

    We sign a HIPAA agreement with every client before we begin the project hence you can be assured that the patient data is divulged to any third-party and be completely secure

  • Best Infrastructure

    We have the state-of-the-art infrastructure in terms of world-class office spaces, uninterrupted network, etc. which enables us to quickly provide all our clients with world-class services

  • Leverage Advanced Software

    We make use of some of the latest and updated versions of the best claims adjudication tools and technologies

  • Quick Turnaround Time

    We have multiple delivery centers around the globe across different time zones, which allow us to deliver the results within a quick turnaround time

  • Qualified Team of Adjudicators

    Our team comprises of highly skilled, talented, qualified, and experienced adjudicators and insurance experts who are capable of catering to any type of client needs

  • Easily Scalable Services

    We have the required bandwidth to easily scale up or down the claims adjudication process as per the client's requirement

  • 24/7 Availability

    We assign a dedicated project manager when you outsource to us who will be a single point of contact for all your queries and project updates 24/7 via phone or email

Outsource Claims Adjudication Services to Us

Outsource2india is a leading company outsourcing claims adjudication services in India and a gamut of other healthcare BPO services to global clients for over 20 years. All our clients have benefited from our high-quality services and operational efficiency. The team at O2I is flexible in adjudicating claims payment by either using the customer's payment system or our own in-house claims system.

Whatever claims adjudication requirements you have, we are capable of taking care of your claims adjudication process needs in a professional manner. Get in touch with us today to discuss your project needs.

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Our Clients

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    Yale School of Management
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    Data Infinity
    Auto MiddleEast
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    Financial Planning Association of Australia
  • International Career Institute
    Carole Holding
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