Pharmacy Billing Adjudication

With years of experience in processing adjudication for leading pharmacies in USA, we understand every type of complication that may arise in the claims adjudication process. Our team is experienced in understanding the various billing requirement and ready to provide customized solutions. We use the steps below to generate, submit and follow up on claim processing to ensure maximum reimbursement. The five steps are:

01. Initial Processing Review

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

  • The wrong patient name or incorrect spelling.
  • The subscriber identification number or plan number is wrong.
  • The place of service code is wrong.
  • The date of service is wrong.
  • The diagnosis code is missing or invalid.
  • The patient’s gender does not match the type of service.

When a claim is rejected for any of the above reasons, it can simply be corrected and resubmitted for payment.

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 –

  • Pre-certification or authorization is not present.
  • Pre-certification or authorization is not valid.
  • The claim submitted is a duplicate claim.
  • The timely filing deadline has passed.
  • The diagnosis or procedure code is invalid.
  • The services performed are not medically necessary.

03. Manual Review

In the manual review, claims are checked by medical claim examiners.  It is not uncommon for nurses or physicians to also manually review these claims during this process.  Medical records may be requested to compare the claim with the medical documentation.  This can be conducted for any type of procedure but most commonly with an unlisted procedure to determine medical necessity.

04. Payment Determination

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

  • Paid: When the claim is considered paid, the payer determines that the claim is reimbursable
  • Denied: When the claim is considered denied, the payer determines that the claim is not reimbursable
  • Reduced: When it is determined that the service level billed is too high based on the diagnosis, the procedure code can be down coded to a lower level deemed appropriate by the claims examiner

05. Payment

The payment submitted to the medical office supplied by the insurance payer is called a remittance advice or explanation of payment.  It details the notice of and explanation reasons for payment, reduction of payment, adjustment, denial and/or uncovered charges of a medical claim. It includes the following data –

  • Payer Paid Amount
  • Approved Amount
  • Allowed Amount
  • Patient Responsibility Amount
  • Covered Amount
  • Discount Amount
  • Adjudication Date

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