The process through which a claim is evaluated and determined to be valid or not is known as what?

The process through which a claim is evaluated and determined to be valid or not is known as claims adjudication. This stage involves a thorough review of the claim submitted by a healthcare provider to ensure it meets specific criteria and guidelines set by the insurance company or payer. During adjudication, the claim is assessed for accuracy, completeness, and adherence to policy terms, including verification of the patient's coverage and eligibility.

Claims adjudication is key in determining whether the claim will be approved for payment, denied, or subjected to further investigation. The outcome can affect healthcare providers' revenue as well as patient billing. This process encompasses various activities including checking for medical necessity, confirming the appropriateness of services rendered, and ensuring all required documentation is present.

In contrast, claims submission refers to the act of sending a claim to the insurance company. Claims processing includes the broader spectrum of all activities that occur from the claim's submission to the resolution of payments but does not specifically denote the evaluation aspect. Claims validation is not a commonly used term in the context of insurance claims; it may imply verifying correctness but is not as precise as adjudication in defining the decision-making process regarding claim acceptance or rejection.