Health Care Insurance Claims Processing & Management Workflow:
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1. Health Insurance Receipt Processing: This process consists of various systems which receive health claims and supporting documents by a variety of different sources. Health Claims are received electronically, for example, from health claims clearing houses, Health Maintenance Organizations (HMOs), and some physicians. They had also received "electronically" via Fax. Finally, health care paper claims are received by mail. All these are logged by assigning a unique identifier. Health insurance paper claims and supporting documents are scanned.(done)
2. OCR: Generally scanned health insurance paper claims plus files are processed by an ICR (Intelligent Character Recognition) process to determine what kind of document it is. Each health document is then subjected to form dropout whereby standard form lines are eliminated), deskewing (to right the image), and despeckling (to eliminate random scan errors). The processed image is then run through an OCR (Optical Character Recognition) process to capture the data associated with each form field.
3. Repair & committal: Fields with sufficiently low confidence levels are subjected to a manual repair health insurance data entry process. If needed, the health document is rescanned. In addition to that, certain types of health care claims images that cannot be processed by OCR are transmitted to an offshore data entry vendor for keying, plus keyed data transmitted back. At last, all images are committed to optical disk and logged into an index database, plus health claim data loaded to a mainframe-based insurance claims payment system.
4. Provider/Plan match: An automated health insurance claims process continually attempts to match the plan (i.e., the contract under which the claim is being paid) & the health care claims provider (i.e., the doctor) identified on the claim with the providers with which the overall claim processing organization has a contract. If there is not a perfect match, the program identifies the near matches based on soundex technology. This system displays prospective matches to knowledge workers in order of the likelihood of the match, who then identify the correct provider.
5. Auto adjudication: The health claim payment system determines whether a claim can be paid, & how much to pay, if there are no inconsistencies between six key data items associated with the health insurance claim. If there are inconsistencies, the system "pends" (i.e., suspends) the claim for processing by the appropriate claims adjudicator, depending on a number of factors including the plan type,this may answer your question what does health care claims adjudication include; the kind of treatment involved, & the amount of task in each adjudicator's task queue.
6. Adjudication of pended claims: The US health claim adjudicator can access the mainframe system for a claim history or the image system for an image or, for electronic claims, a fabricated representation of the original claim. The healthcare claim adjudicator either approves the claim for payment, specifying the proper amount to pay, generates correspondence requesting extra or clarifying information, or generates correspondence denying the claim, Text processing is supported by link to a standard word processing package. This article content is verified by the author with authoritative sources and is may be accurate, still if you found any typos or anything you feel offtopic, feel free to ask in the comment section at the end of the article.
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