What do most payers use to evaluate claims for payment?

Payers primarily utilize claim edits and automatic denial/review commands within their software systems to evaluate claims for payment. This automated process allows for a swift and consistent review of claims by applying established criteria and rules to ensure that all necessary information is present and that services billed are covered under the patient's policy.

These automated systems can flag inconsistencies, verify patient eligibility, check medical necessity, and ensure that coding is accurate according to current regulations and coding guidelines. Because these processes can handle a high volume of claims efficiently and reduce human error, they are a critical component in the insurance claims evaluation process.

While manual reviews by claims adjusters, third-party audits, and consultations with medical experts are also practices that some payers may employ during the claims evaluation process, they are typically reserved for more complex cases or when a claim is flagged for further review. Automated systems streamline the initial review process, allowing for faster payments and more efficient handling of claims.